LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. 



EPITOME 

OP 

SKIN DISEASES, 

WITH FORMULA, 

FOR STUDENTS AND PRACTITIONERS. 

BY THE LATE 

TILBURY FOX, M.D., F.R.C.P., 

AWD 

By T. COLCOTT FOX M.B, M.R.C.P. 

THIRD AMERICAN EDITION, REVISED AND WITH ADDITIONS. 



BY 
T. COLCOTT FOX, B.A. (Cantab.), M.B. (Lond.), 

PHYSICIAN FOR DISEASES OF THE SKIN TO THE WESTMINSTER HOSPITAL J PHYSICIAN 

TO THE SKIN DEPARTMENTS OF THE NORTHWEST LONDON HOSPITAL, AND TO 

THE BELL STREET DISPENSARY FOR CHILDREN; ASSISTANT PHYSICIAN 

TO THE VICTORIA HOSPITAL FOR CHILDREN; LATE PHYSICIAN 

TO THE ST. George's and st. james's dispensary ; and 

MEDICAL superintendent OF THE FULHAM 

smallpox hospital. 







PHILADELPH 

HENRY C. LEA'S SON & CO 

1883. 



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Entered according to Act of Congress, in the year 1883, 

By henry C. LEA'S SON & CO., 

In the OflBce of the Librarian of Congress, at Washington, D. C. 



D0RNA:N-, PRIJi^TER 



AMERICAN PUBLISHER'S NOTICE. 



The favorable reception accorded to this work 
on both sides of the Atlantic, would seem to show 
that it has realized the object with which it was 
prepared — to afford assistance to the student in 
his early study of dermatology, and to serve as a 
manual for ready reference by the practitioner in 
his daily practice. For this latter purpose it has 
been specially adapted by means of the references 
made in the sections on treatment to the formulse 
at the end of the volume. 

To increase its interest for American readers, 
there has been introduced, on page 31, the classi- 
fication of Dermal Diseases adopted by the Ameri- 
can Dermatological Association. 

Philadelphia, November, 1883. 



PREFACE TO THIRD EDITION. 



Not long after the issue of the Second Edition, 
Dr. Tilbury Fox succunibed to an affection from 
which he had long and patiently suffered. I need 
hardly say that the favorable reception of the Epi- 
tome, by the profession in America, was a source of 
the greatest pleasure to him, for his many valued 
friends there had experience of his enthusiasm for 
the special branch of medicine at which he worked 
so hard. 

The continued kind reception of the little work, 
and the desire to honor my brother's memory, have 
inspired me to spare no pains to make the present 
long-delayed edition increasingly useful and accept- 
able. Much has been amended and rewritten, and 
the work brought into the closest conformity with 
the edition which finds such favorable acceptance in 
Great Britain. 

That the Epitome may continue to find a place 
in a country which claims such a large proportion 
of earnest and eminent workers in Dermatology is 
the hope of 

T. COLCOTT FOX. 

14 Harley Street, London. 

1* 



CONTENTS. 



PART I. 

PAGE 

General Observations on Skin Diseases . .13 

SECTIO:^' I. 

Indications for the Study or Skin Diseases :— 

1. As to the General Character of Skin Diseases . . 13 

2. As to the Mode of Examining Skin Diseases . . 14 

3. As regards Complications . . . . . .17 

4. As regards Modifications of Eruptions . . .17 

SECTIO:^' II. 
Elementary Lesions : — 

Maculae 19 

Wheals or Pomphi 20 

Papules or Pimples ........ 20 

Tubercles 21 

Phymata or Tumors .21 

Vesicles . . . . . . . . . .21 

Bullae or Blebs 22 

Pustules 22 

Squamae or Scales . 22 

Ulceration 23 

Cicatrices or Scars 23 

Excoriation . .24 

Kimae or Eissures or Chaps ...... 24 

SECTION III. 

Classification, or Diagnostic Chart or Skin Diseases : — 
1. Eruptions Occurring in Connection with the Acute, 

Specific, or Zymotic Diseases . . - . . .25 



Vni CONTENTS. 

PAGE 

2. Eruptions, the Local Manifestations of Diathetic 

States 25 

3. Local Inflammations ....... 25 

4. Hypertrophic and Atrophic Diseases .... 26 

5. New Formations 27 

6. Hemorrhagic ........ 27 

7. Neuroses 27 

8. Pigmentar}^ Alterations ...... 27 

9. Parasitic Diseases . . . . . . .27 

10. Diseases of the Glands and Appendages ... 27 

11. Peculiarities of Skin Diseases in the United States . 29 

12. Classification and Nomenclature of Diseases of the 

Skin 31 

SECTION lY. 

The Causes oe Skin Diseases : — 

A. Internal Causes ........ 35 

B. An Innate Disposition in the Skin Tissues Them- 

selves to take on a Diseased Condition ... 36 

C. External Causes . . . . . . . .37 

SECTION Y. 
Diagnosis . 41 

SECTION YL 

Treatment (General Principles) . - . . . .43 

PAET II. 

The Description and Treatment of Skin Diseases, 
Alphabetically Arranged. 

Acarus folliculorum ....... 61 

Acne .......... 61 

Acne rosacea or Rosacea ....... 64 

Alopecia or Baldness ....... 65 

Anaesthesia . . . . . . . . .57 

Angioma, see N^vus. 

Angioma pigmentosum et atrophicum . . . .68 

Anidrosis ......... 58 



CONTENTS. IX 

PAGE 

xViitlinix or Carbuncle ....... 58 

Atrophia -cutis ........ 59 

Baker's and Bricklayer's Itch, see Eczema. 

Barber's Itch, see Tinea sycosis. 

Bed-bug Eruption, see Urticaria. 

Boils, see Furunculus. 

Bromidrosis or Osmidrosis ...... 61 

Canities . , . ....... 62 

Callus, Callositas, or Tylosis ...... 62 

Carcinoma cutis, or Cancer of the skin .... 62 

Carbuncle, see Anthrax. 

Chilblain [Pernio)^ see Dermatitis. 

Chloasma ......... 63 

Chromidrosis .63 

Clavus, or a Corn ........ 63 

Condylomata . . . . . . . . .63 

Cornu cutaneum ........ 63 

Comedones ......... 64 

Dandruff, see Seborrhcea and Pityriasis. 

Dermatitis ......... 64 

Dermatalgia ......... 66 

Dermatolysis, or Pachydermatocele . , . . . QQ 
Dysidrosis ......... 66 

Ecthyma 67 

Eczema .......... 69 

Elephantiasis Arabum . . . . . . .79 

Epithelioma (Epithelial Cancer) of the Skin ... 81 

Epithelioma, Superficial or Plat 82 

Erythema 83 

Erythema multiforme .84 

Erythema nodosum . . 85 

Erythema gangra?nosum, see Gangrene. 

Pavus, see Tinea favosa. 

Peigned Eruptions ........ 86 

Pibroma 87 

Plea Eruption .88 

Fly Eruptions 88 

Pragilitas crinium . .89 

Pramboesia .90 

Preckles, see Lentigo. 



CONTENTS. 

PAGE 

Furunculus, or Furuncle, or the Common Boil . . 92 

Gangrene of the Skin 94 

Grocer's ^atch" 95 

Guinea or Medina Worm Disease . . . . . 95 

Gutta rosacea, or Kosacea, see Acne rosacea. 

Hsematidrosis ......... 96 

Hair, Diseases of the ....... 96 

Herpes 97 

Herpes facialis . . . . . . . .97 

Herpes progenitalis 98 

Herpes zoster, Zona, or Shingles ..... 98 

Herpes iris ......... 100 

Hydroa . . . ,101 

Hydro-adenitis . . . . . . . . 101 

Hyperidrosis 101 

Hypertrichosis 103 

Ichthyosis 103 

Impetigo ' . . . 106 

Impetigo contagiosa ....... 106 

Intertrigo, see Dermatitis. 

Itch, Army Itch, Malabar Itch, see Scabies. 

Keloid, or Kelis 108 

Lentigines . . . ' . . . ." . . 109 

Lepra 110 

Lepra arabum, Elephantiasis grsecorum, True Leprosy . 110 
Leprosy, Anaesthetic or Non-tuberculated . . .112 
Leprosy, Tuberculated . . . . . . .114 

Leucoderma, or Vitiligo, or Leucopathia . . . 116 
Lice, see Phthiriasis. 
Lichen tropicus, see Miliaria. 

Lichen 118 

Lichen pilaris 118 

Lichen planus ......... 119 

Lichen urticatus, see Urticaria papulosa. 

Lichen scrofulosorum . . . . . . . 121 

Lipomata . . . . . . . . .122 

Lupus 122 

Lupus vulgaris 123 

Lupus erythematosus ....... 124 

Lymphadenoma cutis . . . . . . .128 

Medicinal Eruptions 129 



CONTENTS. 



XI 



PAGE 

Melanoderma, or Melanopathia, or Melasma . . .132 

Miliaria ,. 133 

Milium, or Grutum 134 

Molluscum contagiosum . . . . . . .135 

Morphoea 136 

Nail Affections . . 139 

Nsevus . . . . . . . . . . 141 

Onychomycosis . . . . . . . . 143 

Pediculi, see Phthiriasis. 

Pemphigus . 143 

Phthiriasis, Pediculosis, and Lousiness ..... 146 

Phthiriasis capitis, or Pediculosis capillitii . . . 146 

Phthiriasis pubis . . . . . . . . 147 

Phthiriasis vestimenti 147 

Pityriasis . . 149 

Pityriasis rubra 149 

Porrigo .......... 150 

Prickly heat, or Lichen tropicus, see Miliaria. 

Prurigo .......... 151 

Pruritus 152 

Psoriasis 154 

Purpura 158 

Rhinophyma, see Acne rosacea. 

Rhinoscleroma . . . . . . . .161 

Ringworm, see Tinea. 
Rodent Ulcer, see Epithelioma. 

Roseola 162 

Rupia, see Syphilis. 

Scabies, or the Itch 163 

Scleroderma 166 

Scrofuloderma . . . . . . . . . 169 

Seborrhoea 170 

Septicsemic and Pysemic Eruptions 172 

Shingles, see Herpes zoster. 

Strophulus, or Red gum .172 

Sudamina, or Miliaria crystallina . . . . .173 

Sycosis .......... 174 

Syphilodermata, or Syphilides 175 

Syphilis, Acquired 176 

Syphilide, Macular or Roseolous 180 

Papular .180 



Xll CONTENTS. 

PAGE 

Syphilide, Yesicular 182 

Pustular or Pustulo-crustaceous .... 182 

Pigmentary 184 

Tubercular or Nodular . . . . . .184 

Syphilitic gummata ....... 185 

Syphilitic alopecia ........ 186 

S^^philitic on3^chia and perionychia . . . . .186 

Hereditary S^^philis . . . . . , .186 

Erythematous macular syphilide . . . .189 

Tinea . 191 

Tinea favosa 192 

Tinea trichophytina . 194 

Tinea circinata . . . . . . ..195 

Tinea tonsurans ........ 197 

Tinea sycosis ......... 199 

Tinea trichophytina unguium, see with Tinea favosa 

itiiguium under Onychomycosis. 
Tinea versicolor ........ 202 

Teleangeiectasis ........ 203 

Ulcus Orientalis 203 

Urticaria, or Nettlerash ....... 205 

Vaccinal Eruptions ........ 208 

Yerrucse, or Warts . . . . . ■ . . . 208 

Xanthelasma, or Yitiligoidea ...... 209 

Xeroderma, see Ichthyosis and Angioma. 

PART III. 

Cutaneous Phaemacopgeia. 

Baths 213 

Fumigation . . 214 

Caustics ...... ... 215 

General Applications . . . . . . .216 

Plasters 228 

Dusting Powders ........ 229 

Special Stimulants for the Scalp 230 

Depilatory 331 

Kemedies for Scabies and Phthiriasis . . . . 231 

Remedies for Yegetable Parasitic Diseases . . . 232 

Internal Remedies ........ 234 

Diet in Skin Diseases . . . . . . . 238 



EPITOME OF SKIN DISEASES. 



PAET I. 
GENERAL OBSEEVATIONS OX SKIN DISEASES. 



SECTION I. 

INDICATIONS FOR THE STUDY OF SKIN DISEASES. 

In order that the clinical study and the therapeutic 
management of the skin may be most successfully prose- 
cuted, one or two very important considerations, concern- 
ing, on the one hand, the general nature of cutaneous 
changes, and, on the other hand, the mode of examining 
those suffering from these maladies, must never be lost 
sight of. 

First. As to the General Character of Skin Diseases. — 
There is nothing really special in the pathology of these 
maladies. It has been a common remark that the study 
of skin diseases is bewildering on account, amongst other 
reasons, of the infinite variety of forms and aspects as- 
sumed by eruptions, and consequently the multitudinous 
names given thereto, names so entirely unlike those ap- 
plied to diseased changes in other parts of the body as to 
lend material support to a belief in an essential peculiarity 
in the nature of diseases of the skin. But recent researches 
in cutaneous pathology have certainly cleared the way to 

2 



14 INDICATIONS FOE THE 

a more correct knowledge of skin affections. Difficulties 
are rapidly vanishing, especially by the breaking down of 
many artificial distinctions which have so multiplied varie- 
ties and terms, and which are in course of being shown 
to have no foundation in fact. It is also now manifest 
that the morbid processes that take place in the skin are 
similar to those observed in other parts of the body. In- 
deed, it is yearly becoming more and more possible to 
group skin diseases according to their pathological affini- 
ties exactly on the same plan as other diseases are classified 
in this respect. It is a noteworthy and satisfactory cir- 
cumstance that the student of to-day, who is compelled to 
acquire pathological knowledge over a wide field, discovers 
that the study of skin diseases is rendered comparatively 
easy because of the general similarity which has now^ 
been demonstrated between the facts of general and skin 
pathology. The student does not find himself dealing with 
strange topics or data, but recognizes, in morbid action, 
familiar appearances, changes and causes, w^hen he turns 
from his study of the diseased states of other organs to 
deal specially with those of the integument in its several 
parts. It is all-important, then, to understand that tb.ere 
is nothing essentially special, beyond the existence of special 
structures, in the details of cutaneous pathological changes 
as compared with those which occur in other parts. 

Secondly. As to the Mode of Examining Shin Diseases. 
— In diagnosing eruptions a great error is commonly com- 
mitted by attempting to recognize them from a too partial 
examination of the phenomena they present either to the 
senses of the practitioner or in their histories. Practi- 
tioners and students, as a rule, content themselves with 
diagnosing from sight alone ; they make a venture at the 
diagnosis from the aspect alone, but only to be often sig- 
nally wrong. In some, and indeed many cases, no doubt 



STUDY OF SKIN DISEASES. J5 

the nature of the disease can be made out correctly at 
once froin inspection, even when that is of a very partial 
kind, inasmuch as the eruption assumes from the outset, 
and preserves throughout its course, its typical characters. 
In other instances, on the contrary, this is difficult or im- 
possible without careful inspection of many parts of the 
disease in several localities in a given patient, or an in- 
quiry into the previous history of its course. For many 
skin diseases are made up of stages, and, at the time of 
observation, these may vary greatly in different parts, 
whilst the typical characters may not be distinctly recog- 
nizable, or may be masked by accidental concomitants. 
And, further, it is important to observe that parts only or 
stages of different diseases often present a likeness to one 
another, and may convey a very imperfect picture of the 
disease. To avoid error, then, the diagnosis should be 
based upon the phenomena or features presented by any 
given disease as a whole, and not upon any particular 
portion of that disease. 

It follows, therefore, from what has just been said, that 
there are two useful rules to be observed in making a diag- 
nosis. The first is this : 

All diseased places, or as many as possible, in a patient 
should he carefully examined, and not one only, or one here 
and there ; for the simple reason that the eruption may he at 
very different stages of development, and therefore present 
divers aspects, in different localities in the sa/me patient. 

The object of this examination is to trace out the origin 
and course of the disease, and to link together the various 
stages into a complete history, which will answer in its 
clinical features to an authoritative standard description of 
the disease, whatever it may be. During this examination, 
special attention should be directed to the character of the 
newest developments, and, if there be none of the kind, to 
the extending edge of patches, which always constitutes 



16 INDICATIONS FOR THE 

the raost recently developed parts of the disease, and, 
therefore, best portrays the primary lesion. Complications 
are also more likely to be recognized by attention to this 
point. 

The second rule is this : 

Where the earlier stages in any given case are not recog- 
nizable, careful inquiry should be made into the history, by 
interrogation of the patient, as to the changes that have oc- 
curred before the disease came under observation, with a view 
to discover its nature. 

Very frequently no fresh developments of the eruption 
are taking place at the time of observation, and no exten- 
sion of a given patch has occurred for some time. The 
malady has, in fact, become chronic and indolent, and, 
moreover, has lost its typical features, oftentimes. The 
only way of making a diagnosis under these circumstances 
is by observing this second rule. For example, eczema is 
characterized mainly by a considerable serous exudation 
which discharges from the surface, but the discharging 
stage has frequently been passed before the case comes 
under the care of a medical man, and the disease may 
present a dry and scaly appearance, and be readily mis- 
taken for psoriasis — a not infrequent error. Again, a dis- 
ease essentially papular may be masked by secondary exu- 
dation and incrustation, and its true nature may therefore 
be overlooked, unless its history be carefully inquired into. 

At the same time, the extent of distribution, the sites in- 
volved, the pattern of the eruption, and its mode of evolution 
and spread should be noted. Many diseases have favorite 
sites, a knowledge of which is very necessary ; others tend 
to assume a particular configuration, as lichen scrofulosum ; 
and others, again, spread in a special way, as ringworm. 

By the observance of these rules, the observer ascertains 
what are the elementary lesions, and the characters of the 
different stages of the several eruptions ; and he should 



STUDY OF SKIN DISEASES. 17 

form with these a picture of the malady, and so make an 
accurate diagnosis, just as the child with his dissected 
puzzle puts together the animal or landscape, bit by bit, 
to form the desired whole. It is well to get into the habit 
of diagnosing a disease both by its positive characters and 
by the exclusion of all other possible affections. 

Thirdly. As regards Complications. — It should never 
be forgotten that two or more eruptions may occur to- 
gether, and in this case their several characters will be 
mingled in varying proportions. Examples of this are 
found in the concurrence of urticaria and eczema, of 
syphilitic rash and chloasm.a, of lichen and urticaria, of 
ecthyma and the dermatitis of scabies, of purpura and 
urticaria, of leprosy and scabies, and so on. The possi- 
bility of the coexistence of two diseases should never be 
lost sight of. Multiformity of eruption is, however, by no 
means sufficient evidence — although it is suggestive — of the 
coexistence of two or more distinct diseases. There are 
three diseases, however, which are essentially multiform in 
eruptive character. They are eczema, scabies, and syphilis. 
Supposing, therefore, that neither of these diseases is pres- 
ent, multiformity of eruption usually indicates the co- 
existence of two or more eruptions. 

Fourthly. As regards Modifications of Eruptions. — 
There are many influences which modify the aspect and 
the general character and behavior of skin diseases, which 
should be taken into account in dealing with their treat- 
ment. It is not only necessary that the physician should 
recognize any particular form and kind of skin eruption, 
but that he should appreciate the part played by various 
concomitant conditions in each individual, which modify 
the character and the duration of the particular disease 
present. There are various diatheses, special states of the 

2^ 



18 INDICATIONS OF SKIN DISEASES. 

blood, of nerve, and of tissue which specially tend to in- 
duce an unusual amount of inflammatory action, or favor 
undue pus formation, or disorder of sensation, and the 
like, to which due consideration must be given. The evil 
influences of such conditions must be thwarted, so as to 
pave the way for the proper action of curative measures 
directed against the disease as a disease in the abstract. 

A few useful particulars or hints may not inappropriately 
be given here. Diseases of the skin are spread or take on 
an inflammatory character, or the changes in the skin are 
exaggerated, by exposure to all irritating agencies, such 
as heat, cold, scratching, the contact of acrid substances of 
all kinds, as in the handling of lime, sugar, soda, respec- 
tively, by bricklayers, grocers, and washerwomen. So, too, 
an inflammatory aspect is given to eruptions by acridities 
in the blood, as in gouty or rheumatic subjects, in dyspep- 
tics, and in those in whom the bile-acids, sugar, or retained 
efiete matters are present in undue amount in the blood. 
Eruptions in strumous subjects and in children are attended 
by an amount of pus formation which is unusual in non- 
strumous subjects and in adults. Undue chronicity is oc- 
casioned oftentimes by the existence of nervous or general 
debility; for Nature then lacks the natural recuperative 
power, and cannot exert it in aid of the cure. 

The questions of age, sex, occupation, mode of life, and the 
general medical history of the patient have to be considered, 
and will be incidentally referred to in other places, but 
due attention to the four indications already discussed will 
be found of essential importance in the successful diagnosis 
and treatment of a skin disease. It may be observed, how- 
ever, as regards age, that one essential difierence between 
the cutaneous diseases of the young as compared with those 
occurring in the middle-aged and old, consists in the fact 
that the former are often the result of imperfect digestion 



ELEMENTARY LESIOXS. 19 

and assimilation, ^Yhereas the latter are induced by roal- 
influences connected with the habits and occupations and 
wear and tear of adult life, and degeneration of structure 
in the old, and are modified by a number of functional and 
organic diseases of internal organs, which are conspicuous 
by their absence in the young. 



SECTIOX II. 

ELEMENTARY LESIOXS. 

The elementary lesions are the types of external form 
and aspect presented by skin eruptions, and with these the 
student is expected to be accurately acquainted. The brief 
description here given will constitute a general outline of 
the pathology of the skin : but it must be remembered that 
there is no hard-and-fast line to be drawn between some of 
the lesions, however necessary their definition may be for 
clinical purposes. 

MaculaB may be defined as any alteration in the color 
of a circumscribed area of skin from whatever cause, as long 
as it is unattended by any marked depression or elevation 
of the surface. Thus, they may be caused by — 

(a) Slight congestion or superficial inflammation, as 
in erythema simplex, the erythematous syphi- 
lide and lupus, and macular leprosy. Tiny 
points are called pundce, the widely diffused 
stains or blushes discolorations. 
(6) Extravasations of blood into the skin, as in pur- 
pura. Such extravasations are very frequently 
a secondary feature in eruptions. 
(c) Deposition or removal of pigment, which princi- 
pally occurs in the lower rete layers, as in 



20 ELEMENTAKY LESIONS. 

ephelides or freckles, chloasma, leucoderma, 
and leprosy. The deposition of pigment very 
often follows the prolonged congestion or inflam- 
mation of a part, or the resolution of a new 
growth from the breaking up of red blood-cor- 
puscles, as after a blister, urticaria, lichen 
planus, and syphilides. 

(c?) Chemical changes from any external or internal 
source — e. g,, iodine, nitrate of silver, bile-acids. 

{e) The growth of vegetable parasites in the skin, as 
in tinea versicolor. 

(/) New growths or chronic inflammations of the 
corium, as in nsevi or morphoea. 

Wheals or Pom phi are mostly oval or rounded in 
outline (irregular by confluence), or ringed, evanescent 
swellings, brought about by acute transient hypersemia and 
oedema of the skin in localized areas. Wheals, are pinkish 
in color, but the amount of serous fluid effused is frequently 
sufficient to obscure the redness in the central parts, hence 
they are sometimes described as whitish elevations with or 
without a pinkish bordering. They are typically portrayed 
in the effects of the sting of the nettle. It is supposed they 
are caused by the sudden dilatation, under nervous influ- 
ence, of a bunch of capillary vessels, which quickly regain 
their tonicity except in rare cases. Heat and itching or 
stinging or great tingling accompany them. 

Papules or Pimples are solid elevations of the skin, 
mostly of rounded outline, acuminate, or flat-topped, and 
varying in size from punctse up to about a split pea, until, 
in fact, the term ^Hubercle '' is applicable. They may be 
due to hypersemia of little groups of papillse, or very com- 
monly to inflammatory exudation ; and the papillae in both 
cases may be specially involved around the sweat ducts, as 



ELEMENTARY LESIONS. 21 

in miliaria and strophulus ; or sebaceous follicles, as in 
acne ; or the hair-follicles, as in sycosis, and then a hair 
protrudes through the centre of the papule. The inflam- 
matory exudation may be mainly serous as in eczema, or 
more cellular and plastic as in syphilis and leprosy, or 
associated markedly with hypertrophic changes in the 
epithelial cells as in lichen planus and psoriasis. In the 
latter affection and in warts the papillary changes seem to 
be primary. Papules may also be formed by plugging of 
the sebaceous glands by altered sebum as in milium, or by 
the collection of exuviae in the mouth of the follicles as in 
lichen or keratosis pilaris. Lastly, papules may be formed 
by the early stages of new growths of various kinds, either 
cellular as in lupus, or lymphatic as in lymphangioma, or 
connective tissue as in fibroma. 

Tubercles are very large papules or rather nodules, 
and vary in character like papules, but are mostly new 
growths or inflammatory exudations of a special character. 

Phymata or Tumors are solid formations of the size 
of walnuts upwards — e. g., erythema nodosum, fibroma mol- 
luscum. 

Vesicles are upliftings of the epidermis into minute 
dome-shape or acuminate bladders, corresponding in size 
with papules, by either sweat, serosity, or lymph. Vesicles 
frequently represent only a further stage of the inflamma- 
tory exudation process, by the transudation of fluid from 
the bloodvessels in sufficient quantity to pass through the 
rete cells, and the separation of its upper and lower layers. 
They may be simple or compound ; thus simple vesicles 
are due to the collection of sweat between the strata of the 
cuticle (sudamina), or to the serosity between the cuticle 
and rete (pemphigus, vesicating erythema), or to the dila- 



22 ELEMENTARY LESIONS. 

tation and varicosity of lymphatic radicles or blood capil- 
laries. The vesicles in all skin diseases are more or less 
compound, and cannot be emptied by a single pricking, as 
the fluid does not collect in a single chamber, but is retained 
in loculi formed by the stretched-out rete cells — e.g., herpes, 
eczema. Inflammatory vesicles are, as a rule, short-lived, 
and rapidly rupture or collapse to form delicate scales. 
They may go on to form pustules. 

BuUaB or Blebs are simply very large vesicles, and 
their mode of formation is similar. They bear the same 
relation to vesicles that tubercles do to papules. They are 
formed in a variety of aflections besides pemphigus — e, g., 
in erysipelas, occasionally in scabies and erythema multi- 
forme, in herpes iris, in syphilis, and in dysidrosis by the 
coalescence of vesicles. 

Pustules are circumscribed and variously shaped ele- 
vations of the surface, due to the formation of pus. The 
production and collection of pus-cells may be rapid, and 
the pustules appear as such from the first, or a pustule 
may be the ultimate stage of a papule or vesicle, as in 
eczema, scabies, impetigo contagiosa, pemphigus, herpes, 
etc., and is consequently generally loculated, especially in 
the variola pock. In acne and sycosis the pus is deep- 
seated in or about a follicle or gland. Pus formation is 
very frequent in infantile inflammations and in the scrofu- 
lous. Pustules generally have an inflamed areola, and 
frequently end in ulceration and scarring. 

There are also certain secondary changes which must be 
noticed. 

Squamae or Scales are formed of desiccated detached 
epidermic scales, and they differ from crusts, which are 
formed mostly by dried discharge. Some desquamation 



ELEMENTARY LESIONS. 23 

occurs as a secondary consequence of all inflammatory 
skin diseases^ and forms an exceedingly prominent feature 
in two diseases — vir., psoriasis and pityriasis rubra. Scales 
are also formed by the collapsed walls of vesicks. Crusts 
are composed of dried-up discharge — i. e,, serum and pus- 
cells, which have escaped free upon the surface, either 
from an excoriated surface, as in eczema, or from a rupt- 
ured pustule, as in rupia or ecthyma, or from an ulcerating 
surface. Crusts are also formed by masses of fungus ele- 
ments (favus), and by sebum concreted in masses (sebor- 
rhoea). Crusts formed by the escape of serum are thin 
and bright-colored ; by dried pus, thick and yellow ; from 
drying of bull^, as a rule, thin and slightly dark ; by 
drying of sanious pus from ulcers, thick, dark-colored, and 
heaped-up ; from collected dried sebum, flat, easily de- 
tached, and greasy ; and in favus, they are pulverulent 
and sulphur-yellow and discoid. 

Ulceration is usually the result of purulent inflamma- 
tion, strumous or syphilitic, and may occur in cachectic 
individuals as the consequence of eruptions, which, under 
other conditions, do not ulcerate — e. g., vaccinia, varicella, 
herpes. It is very frequently met with, and is characteristic 
of struma and syphilis. Ulceration may also result from 
new grow^ths replacing normal tissues and themselves 
necrosing — e. g., in lupus and cancer. 

Cicatrices or Scars are the signification that the 
corium with its ducts, and hairs, and glands, has been de- 
stroyed by inflammation, ulceration, and replaced by cica- 
tricial tissue. Scars may also result from the replacing of 
normal tissue by a new growth, which in its turn disap- 
pears — e. g., lupus erythematosus. Scars must not be con- 
founded with the scar-like lines and spots formed either by 



24 ELEMENTAKY LESIONS. 

an atrophic process or by stretching — e. g,, in linear atrophy 
and the ^' lines of pregnancy." 

Excoriation is the result of the exposure of the true 
skin by the scratching or tearing of the cuticle and more 
or less of the rete. A dark crust from dried blood or 
serum commonly forms and no scar results. 

Rimae or Fissures or Chaps are cracks in the skin 
due to loss of elasticity from inflammatory infiltration, etc., 
at points where the surface is in constant motion — e. g., 
chronic eczema and psoriasis of the palms of the hands. 

We thus see that the skin is subject to similar patho- 
logical changes as other parts of the body, and differences 
of detail are due to the position of the skin, and the special 
structure of the skin as regards its lymph and blood supply, 
its peculiar nervous apparatus, and the presence of the 
sweat and sebaceous glands and the hairs. The mode of 
distribution of the blood and nerve supply, and the en- 
casing epithelium, mostly determine the peculiar results of 
inflammation in the formation of many of the eruptions. 
The chief pathological changes may be summed up to be 
(1) Hypercemia, or the excessive determination of blood 
superficially and epheraerally, and marked by heat and red- 
ness. (2) Anoemia, which is of little import here. (3) The 
complex process known as Inflammation, either acute or 
chronic, generally involving the epithelium, and marked 
by heat, disordered sensation, redness, swellings, and the 
exudation of more or less serum and corpuscles in varying 
proportion. (4) Hypertrophy of any part or parts of the 
skin, either in bulk or the number of the preexisting 
elements. (5) Atrophy, (6) New growths, or the forma- 
tion of new tissue, either similar in nature to that where 
it occurs (Jiomologous) or different {heterologous). Such 
growths may be benign or malignant. Various degenera- 
tive changes may also occur. 



CLASSIFICATION OF SKIN DISEASES. 25 

S.ECTION in. 

CLASSIFICATION, OR DIAGNOSTIC CHART OF SKIN DISEASES. 

It is not intended here to discuss the classification of 
diseases of the skin. A satisfactory classification is a 
matter for the future, and must needs be unsatisfactory 
whilst the pathological and causal relations of many affec- 
tions remain for solution. 

Ho^yever, for the introduction of some order, the follow- 
ing list, or semi-chart, conveys a good general idea of the 
various eruptions met with in the skin, regarded from a 
clinical point of view. The list comprises : 

1. Eruptions Occurring in Connection with 
the Acute, Specific, or Zymotic Diseases, includ- 
ing the variolous rash, roseola variolosa, vaccinia, and 
roseola vaccinia, the rashes of typhus, typhoid, rubeola, 
rotheln, scarlatina, glanders and farcy, and dengue. These 
are important in reference to the difierential diagnosis of 
skin diseases. 

2. Eruptions, the Local Manifestations of 

Diathetic States, comprising scrofuloderma, or scrofu- 
lous inflammation ; syphilodermata, or syphilitic eruptions; 
leprous eruptions ; framboesia or yaws ; eruptions occurring 
in connection with endemic cachexice, such as Oriental Sore, 
the Paranghi disease of Ceylon, etc. 

3. Local Inflammations, comprising : 
Erythematous inflammation ; the chief feature consists in 

the presence of hypersemia, disappearing under pressure, 
with or without some slight consequent effusion of serosity 

3 



26 CLASSIFICATION, OR DIAGNOSTIC 

and a few leucocytes. It is a superficial inflammation, 
mostly of short duration, and the lesions tend to be 
symmetrical, and spread peripherally within certain limits 
and form rings. The erythematous diseases are 

Erythema multiforme, roseola, urticaria. 
Catarrhal, characterized by serous effusion into papillary 
layer, mostly running on to sero-purulent discharge and 
crusting. The effusion tends to concentrate itself about 
certain points to form vesicles and papules. Under this 
head ranks 

Eczema dermatitis. 
Plastic, essentially papular and chronic, due to effusion 
of plastic lymph and cells into the papillary layer, and 
sometimes the deeper dermic layer, and some hypertrophy 
of epithelial cells, including 

Lichen, prurigo. 
Bullous, the essential feature being the development of 
bullae. It includes 

Herpes, pemphigus. 
Siqopurative, characterized by the development of pus- 
tules as an essential feature, superficial and painless, or 
deeply seated and painful. Pus may form secondarily in 
eczema vesicles, pemphigus bullse, etc. It comprises 

Impetigo contagiosa, ecthyma, furunculus. 
Squamous, characterized by hypersemia of the derma, and 
hyperplastic growth of cuticle ; including 

Pityriasis rubra, psoriasis. 

4. Hypertrophic and Atrophic Diseases : 

A. Hyioertroijhic, 
The epithelial layers may be mainly affected, as in 

Warts, corns, xeroderma, and ichthyosis. 
The connective tissues of the skin may be specially 
involved, as in 

Keloid, fibroma, morphoea, scleroderma. 



CHART OF SKIN DISEASES. 27 

B. Atrophic, Including 
Senile atrophy, linear atrophy, general marasmus. 

5. New Formations, the characteristic being the 
growth of new tissue made up of granulation cells, or 
altered and proliferating connective-tissue cells. This 
group includes 

Lupus, cancer, rodent ulcer, xanthelasma. 

6. Hemorrhagic (cutaneous) effusion of blood, unin- 
fluenced by pressure — in points or patches. Illustrated by 

Purpura. 

7. Neuroses, in ^vhich the nerves are primarily dis- 
ordered, and there are no organic changes at the outset. 
The chief examples are 

Tlyper^esthesia, anaesthesia, pruritis. 

8. Pigmientary Alterations, consisting primarily of 
deposit or alteration of pigment. Pigmentation, secondary 
to other diseases, is not included here. 

Melasma, leucoderma, rank here. 

9. Parasitic Diseases, which comprise : 

A. Animal. 

Scabies, phthiriasis, eruptions due to gnat bites, fleas, 
etc. • 

B. Vegetable. 

Tinea favosa, tinea tonsurans, circinata, and sycosis, 
tinea versicolor. 

10. Diseases of the Glands and Appendages, 

divisible into : 

A. Diseases of the sweat glands and follicles, as excessive 
secretion (hyperidrosis) ; diminished secretion (ani- 



28 CLASSIFICATION, OR DIAGNOSTIC 

drosis) ; altered secretion (chromidrosis, osmidrosis) ; 
congestive and inflammatory (miliaria, sudamina, 
lichen tropicus strophulus, dysidrosis, hydroadenitis) ; 
and sweat cysts. 

B. Diseases of the sebaceous glands, as inflammation with 
excessive secretion (seborrhoea) ; diminished secretion 
(asteatodes) ; altered secretion with retention (milium, 
comedo) ; retention of secretion with hyperplasia of 
the gland (molluscum) ; slight retention with inflam- 
mation (acne). 

C. Diseases of the hair and hairfollicles, as excessive 
growth (hairy nsevi, moles, hirsuties) ; diminished 
growth, constituting partial or absolute baldness 
(alopecia); textural alteration (fragilitas) ; inflam- 
mation of the follicles (sycosis). 

D. Diseases of the nails, including changes occurring in 
syphilis, lichen ruber, general eczema, psoriasis, 
pityriasis rubra, and struma; inflammation of the 
matrix, as in onychia; parasitic disease termed ony- 
chomycosis, caused by the favus parasite or the tri- 
chophyton ; hypertrophy, atrophy, and corn of the 
nail. 

There are then ten groups of skin diseases — viz., the 
eruptions of the Acute Specific Diseases; Local Inflamma- 
tions ; Diathetic Diseases ; Hyper- and A-trophic Disease ; 
New Formations ; Hemorrhagic, Neurotic, and Pigmentary 
Diseases ; Disorders of the Hair and Glands and their Ap- 
pendages. Such is the clinical classification that may be 
given at an examination. Every skin disease must fall 
into one of these groups, and it soon becomes an easy 
matter to refer any disease before the observer to its proper 
class. 



CHART OF SKIN DISEASES. 29 

[Peculiarities of Skin Diseases in the United 
States. 

It is a well-known fact that a malady often undergoes 
definite modifications under changed external conditions, 
such as altered climatic and hygienic surroundings. In- 
deed, the subject of the geographical distribution of disease 
has ever afforded an attractive field for the medical phil- 
osopher ; furnishing, as it does, data wdiich, if thoroughly 
appreciated, may prove to be valuable evidence both as to 
the etiology and the claims for specific character of certain 
disorders. The medical profession in the United States 
have no reason to be ashamed of the labors and results of 
those of their number who have especially cultivated the 
subject of skin diseases ; for their recorded observations 
and careful investigations have contributed materially to 
the progress of modern dermatology and its establishment 
upon sound scientific principles. From their experience 
we learn that there are not only some generally recognized 
variations in type of certain skin afiTections, but also that 
there are others, which, though quite frequent in their 
occurrence in Europe, are rarely met with in America, and 
vice versa. 

A general agreement among dermatologists upon the 
subjects of pathology and nomenclature of skin diseases 
w^ould alone enable such a rigid contrast to be made as 
would completely sa-tisfy the demands of science. Such an 
exact comparison is not practicable at present, although a 
rapidly increasing consensus of opinion among systematic 
writers upon these subjects, more particularly observed in 
the last quarter of a century, warrants the hope that this 
may be accomplished in the near future. 

In the mean time w^e may, in a general way, formulate 
the prominent characteristics of skin disorders as they occur 

3- 



80 CLASSIFICATION, OR DIAGNOSTIC 

in this country. Prof. James C. White/ of Harvard, from 
a careful study of American statistics and extended per- 
sonal observation, has arrived at the following conclusions: 

I. Certain obscure affections, the etiology of which is 
little if at all understood, even in those parts of Europe to 
which they are mostly confined, may be regarded as prac- 
tically non-existent among us. Such are lorurigo, iDellagray 
and lichen exudativus ruber, 

II. Certain diseases, directly connected with and de- 
pendent upon poverty and habits of personal uncleanliness, 
are less prevalent in the United States than in those parts 
of Europe of which we have sufficient statistical informa- 
tion for a comparison. Examples of this class are the 
animal parasitic affections especially. 

III. Some cutaneous affections of grave character, which 
are dependent upon or form a part of serious constitutional 
disorders, are of less frequent occurrence amongst us than 
in Europe in general, or those parts of it where they are 
endemic. Lupus, the sypMlodermata (?), and leprosy are 
the most marked instances of this class. 

IV. Certain disorders of the skin, especially those of its 
glandular systems and those connected more immediately 
with its nervous system, are apparently more prevalent 
with us than in Europe. ' The most notable examples of 
the former are seborrhcea, acne, and possibly the heat-rashes ; 
of the latter, herpes, urticaria, and pruritus. 

In addition to these valuable observations, it may not be 
amiss to call the reader's attention to the limitation of 
leprosy (elephantiasis grsecorum) within particular districts. 
Existing in India, China, Egypt, certain parts of Norway 
and Sweden and the Sandwich Islands, true leprosy is only 
very rarely encountered in the United States, and almost 
never in the person of a native. It may be found among 

1 Trans. Int. Med. Congress, 1876, Phila., 1877, p. 681. 



CHART OF SKIN DISEASES. 31 

immigrants in the Norwegian settlements in the Northwest ; 
also among the Asiatics in California. It is also seen in 
Central America and Mexico, but is probably never en- 
demic in this country. 

Syphilitic skin diseases are as common in America as in 
Europe, and w^hen neglected are doubtless equally severe 
in their manifestations ; but in this country they are less 
frequently accompanied by such profound degradation of 
the system under the influence of accompanying filth, 
poverty, and insanitary surroundings, than they are in 
foreign countries. Lupus vulgaris, according to Dr. Duhr- 
ing, is much milder here than in Europe ; and cases of 
lupus erythematosus are relatively much more common in 
America. 

At the last meeting of the American Dermatological 
Association^ the following Classification and Nomen- 
clature was adopted : 

CLASSIFICATION AND NOMENCLATURE OF DIS- 
EASES OF THE SKIN. 

ADOPTED BY THE AMERICAN DERMATOLOGICAL ASSOCIATION. 

Class I. — Disorders of the Glands. 
1. Of the Sweat Glands, 
Hyperidrosis. Bromidrosis. 

Miliaria crystallina. Chromidrosis. 

Anidrosis. 

2. Of the Sebaceous Glands, 
Seborrhoea. Cysts. 

(a) oleosa. (a) milium. 

(6) sicca. (b) wen. 

Comedo. Molluscum sebaceum. 

Diminished secretion. 

1 Held at Saratoga, August, 1878. 



32 



CLASSIFICATION, OR DIAGNOSTIC 



Class II. — Inflammations. 



Exanthemata. 
Erythema simplex. 
Erythema multiforme. 

(a) papulatum. 

(6) bullosum. 

(c) nodosum. 
Urticaria. 
Furuncle. 
Anthrax. 

Phlegmona diffusa. 
Pustula maligna. 
Herpes. 

(a) facialis. 

(b) progenitalis. 
Herpes zoster. 
Psoriasis. 
Dermatitis.^ 

(a) traumatica. 

(b) venenata. 

(c) calorica. 



Pityriasis rubra. 
Lichen. 

(a) planus. 

(6) ruber. 
Eczema. 

(a) erythematosum. 

(6) papulosum. 

(c) vesiculosum. 

(d) madidans. 

(e) pustulosum. 
(/) rubrum. 
(g) squamosum. 

Prurigo. 

Acne. 

Impetigo. 

Impetigo contagiosa. 

Impetigo herpetiformis. 

Erysipelas. 

Ecthyma. 

Pemphigus. 



Class III. — Hemorrhages. 



Purpura. 
(a) simplex. 



(6) hsemorrhagica. 



Class IV. — Hypertrophies. 
1. Of Pigmemt 
Lentigo. Chloasma. 

(a) locale. 

(b) universale. 

1 These indicating affections not properly included under other 
titles of this class. 



CHART OF SKIN DISEASES. 



33 



2. Of Epidennal and Papillary Layers, 



Keratosis. 

(a) pilaris. 

(6) senilis. 
Callositas. 
Verruca. 
Clavus. 



Cornu cutaneurii. 
Verruca necrogenica. 
Xerosis. 
Ichthyosis. 
Ichthyosis of nail. 
Hirsuties. 



3. Of Connective Tissue, 

Scleroderma. Rosacea. 

Sclerema neonatorum. (a) erythematosa. 

Morphcea. (h) hypertrophica. 

Elephantiasis Arabum. Framboesia. 



Leucoderma. 
Albinismus. 



Class V. — Atrophies. 
1. Of Pigment, 
Vitiligo. 
Canities. 



Alopecia, 
jilopecia areata. 



Atrophia senilis. 



2. Of Hair, 

Alopecia furfuracea. 
Atrophia pilorum propria. 

3. Of NaU, 

4. Of Cutis, 

Atrophia maculosa et striata. 



Keloid. 

Cicatrix. 

Fibroma. 



Class VI. — Kew Growths. 
1. Of Connective Tissue, 
Neuroma. 
Xanthoma. 



31 



CLASSIFICATION OF SKIN DISEASES. 



2. Of Vessels, 
Angioma. Angioma cavernosum. 

Angioma pigmentosum et Lymphangioma, 
atrophicum. 

3. OJ Granulation Tissue. 



Khino-scleroma. 
Lupus erythematosus. 
Lupus vulgaris. 
Lepra. 

(a) tuberosa. 

(&) maculosa. 

(c) ansesthetica. 
Scrofuloderma. 



Syphiloderma. 

(a) erythematosum. 

(6) papulosum. 

(c) pustulosum. 

(c/) tuberculosum. 

(e) gummatosum. 
Carcinoma. 



Class VII. — Ulcers. 



Hypersesthesia. 
(a) pruritus. 
(6) dermatalgia, 



Class VIII. — Neuroses. 
Anaesthesia. 



Class IX. — Parasitic Affections. 



Tinea favosa. 
Tinea tricophytina. 
(a) circinata. 



Scabies. 
Pediculosis capitis. 



1. Vegetable, 

(h) tonsurans, 
(c) sycosis. 
Tinea versicolor. 

2. Animal, 

Pediculosis corporis. 
Pediculosis pubis. — Ed.] 



THE CAUSES OF SKIN DISEASES. 35 

SECTION lY. 

THE CAUSES OF SKIN DISEASES. 

In the previous Section a general summary has been 
given of the different varieties of skin diseases, in the form 
of a tabular classification. 

In this Section a sketch of the causes of these diseases 
will be given. Such causes as are not due to congenital 
aberrations of nutrition or improper development may be 
conveniently ranged under three heads: 

A. Those ivliich ad from within the system upon the shin; 

or INTERNAL CaUSCS. 

B. An innate disposition in the shin tissues themselves to 

take on a diseased action, 
0. Those ivhich act from without the system upon the shin; 

or EXTERNAL CaUSCS. 

Opinions differ greatly as to the relative frequency of 
the operation of these several factors in the causation of 
skin diseases. Many of the causes in groups A and B are 
hereditary. Age and Sex have also an important bearing 
with respect to the structure of the skin, and its proneness 
to take on diseased action and the development of certain 
special functions. 

A. Internal Causes. — Amongst these the most im- 
portant are : 

a. Alteration of the normal healthy character of the blood 
by special poisons, inducing specific eruptions, as in the 
acute exanthemata, in pysemia and septicaemia, in syphilis, 
and probably leprosy ; by the presence of certain medicinal 
substances, e. g., potassium iodide and bromide, copaiba, 
arsenic, belladonna, etc., which irritate various tissues 



o6 THE CAUSES OF SKIX DISEASES. 

under certain conditions; by the accumulation of morbid 
products, -wliich excite eruptions or impart an inflammatory 
character to them, or render tissues prone to inflammation, 
as in gout and rheumatism; by the imperfect fulfilment by 
organs of their natural functions, as menstruation, digestion 
and assimilation, perspiration, sebum formation, and hepatic, 
intestinal, and renal excretion, whereby harmful substances 
enter the blood current or are retained in it in undue pro- 
portion ; by indulgence in special articles of food, either in 
excess or of a deleterious character (shell fish, bad fish) ; 
and by impoverishment by depraved habits, overwork, ex- 
cessive demand for pabulum, climatic influence, etc. 

6. Nerve disturbance, which acts in several ways, first, 
by inducing changes in the calibre of the vessels by which 
the blood supply and fluid transudation are affected, as in 
hypersemia and urticaria ; secondly, by directly encourag- 
ing morbid tissue changes as in herpes and pemphigus, and 
dystrophic affections ; and, thirdly, by the loss of control 
over the skin nutrition, which often follows from impaired 
functional power, allowing morbid action of all kinds to 
take place more readily. The nerves may be influenced 
directly as in herpes and anaesthetic leprosy, or reflexly 
from some disordered organ — e.g., the stomach or uterus, as 
in urticaria. 

B. An Innate Disposition in the Skin Tissues 
Themselves to take on a Diseased Condition.— 

This is a point on which special stress is laid. It is pretty 
certain that many diseases of the skin must originate in a 
disordered behavior of the tissues themselves, and do not 
necessarily depend for their cause upon any general defect 
of nutrition. For instance, cancer is a case in point ; and 
so also warty growths of all kinds, fibroma, keloid, and 
perhaps lupus, are other illustrations of the same thing. In 
some cases there is just an excess of growth, a plus state of 



THE CAUSES OF SKIN DISEASES. 37 

the nutrition of the tissue and nothing more ; or it may be 
a minus condition. In other instances it is a perverted 
nutrition, a deviation in the type of the tissue, as in cutane- 
ous cancer. In fact, Group 4, and many of the diseases in 
Group 10 of the classification illustrate this point. It is 
asserted by most writers that such changes — hypertrophy 
and atrophy — are, in reality, merely the consequence of the 
presence in the blood of a greater or less amount of the 
pabula of the particular tissues affected. But if these 
pabula be in excess, which is unproved, the hypertrophy 
would not occur unless the tissues were disposed to make 
use of them fully, and if such a disposition existed in a 
degree less than that of healthy nutrition, atrophy would 
result. So that, after all, the 'Normative capacity" of the 
tissues themselves is an important element in these plus and 
'mi^n(.i states of growth ; and the explanation given above 
may be true, for if the tissues themselves exhibit a tendency 
to hyperplasia, x^ature will answer the demand for an 
increased supply of pabulum. In the case of perverted 
nutrition (heterologous formation) the changes are ex- 
plained more readily by a perversion of the " formative 
capacity " than by altered character of growth the conse- 
quence of a supply of a modified kind of pabulum. 

C. External Causes. — Some of these influence the 
general health for evil, and so disorder the skin indirectly; 
others act directly upon the skin. 

1. Amongst the external causes acting directly upon the 
skin, the most important are : ScratcJdng, which may excite 
and always aggravates disease, and may, in contagious cases, 
spread it from place to place, as in scabies and contagious 
impetigo. Local irritants of all kinds — e. g., cold, heat, fric- 
tion, pressure, flannel worn next the skin, irritants, plasters, 
fluids, and applications of all kinds ; irritating substances, 
such as lime, sugar, flour, washing soda, producing brick- 

4 



38 THE CAUSES OF SKIN DISEASES. 

layers', bakers', grocers', and washerwomen's itch ; unwhole- 
some handicrafts ; dyes, contusions, animal and vegetable 
parasites of all kinds ; medicinal applications and ivant of 
care of the skin in the dirty and ill-fed ; many of these 
causes only set up inflammation when the system is spe- 
cially predisposed by disordered health. The influence of 
occupation is well illustrated by the occurrence of callosities 
in certain regions. 

2. Here may be mentioned also the causation of such 
local diseases as Elephantiasis Arabum, and Guinea-worm 
disease, by the introduction of parasites into the system 
through the stomach. 

3. Amongst the external causes that act indirectly upon 
the skin, through their influence upon the general health, 
may be mentioned : Want of cleanliness, climatic influences, 
defective clothing, neglect, and the like; animal poisons 
inoculated into the skin, etc. 

Clinically, it is of the highest moment to be acquainted 
with the fact that, as a rule, these several causes not only 
vary in character, but do not operate in a solitary or indi- 
vidual way. To put it in another way : (1) these influences 
or agencies are, in reality, divisible into predisposing, ex- 
citing, producing, and intensifying causes; and, further, (2) 
the true cause of the state of any given disease is made up of 
a number of phenomena or agencies in combined operation. 
These are points of great practical importance in reference 
to the treatment of skin diseases. 

In reference to the first point, it may be said that many 
so-called local causes only predispose to, though they 
usually excite, eruption. For instance, debilitating occu- 
pations render a man much more liable to be afiected by 
the handling of irritants ; in a bad climate, the system 
generally is disordered in addition to the skin, and the 
latter is so rendered more liable to become diseased. Other 
causes act as pure excitants, as when there is a predisposi- 



THE CAUSES OF SKIN DISEASES. 39 

tion to a disease — e. g.^ eczema, and the local irritant excites 
it, but probably would not if acting without the existing 
predisposition. Some influences, however, are really pro- 
ducers of disease, as in the case of medical irritants or spe- 
cial poisons — e. g., malignant pustule. Other agencies again 
only aggravate existing disease, as in the case of the wear- 
ing of flannel, or exposure, or scratching. 

In reference to the second point, it is indisputable that, 
in most cases, several agencies or influences, external or 
internal in origin or operation, combine to make up the 
true cause of a disease, and it is the duty of the physician 
to recognize this fact and analyze very carefully the com- 
posite cause of skin troubles. In fact, in such correct 
analysis lies the source of all successful dermatological 
treatment. From a therapeutical point of view, diseases 
of the skin are very different things as portrayed on paper 
and as seen in the consulting-room. A disease may answer 
most perfectly to the typical description, but the remedies 
ordered for its cure may signally fail, because the analysis 
of its causation is incorrect or incomplete. For diseases 
are greatly modified as they occur in different subjects, and 
it is not the uncomplicated type that is to be dealt wdth in 
practice, but the disease modified and influenced by the 
many concomitant conditions of age, constitution, occupa- 
tion, etc. 

It may be useful to mention a few common combinations 
met with clinically, which illustrate the multiform char- 
acter of the causation of skin diseases, as seen in the con- 
sulting-room. In the case of eruptions provoked by local 
irritants, referred to above, there is very frequently debility 
present which favors the development of the disease, and 
which must be got rid of if the eruption is to get well, and 
if it is to be cured in the best way. In fact, the skin of a 
healthy person will mostly resist the action of many of the 
local irritants specified, but the skin cannot do so if the 



40 THE CAUSES OF SKIJST DISEASES. 

subject be weak and debilitated ; so that it is an important 
point to give tonics as the rule in cases of eruptions excited 
by local irritants. This simple combination of causes, 
debility and local irritants, is often found inducing simple 
or eczematous inflammation, etc. Other examples readily 
occur, such as eczema in a gouty subject, modified by 
neglect and scratching ; psoriasis in a strumous subject, in 
whom the tendency to the disease is hereditary ; erythema in 
a rheumatic subject, in connection with dyspepsia ; eczema 
occurring in cooks exposed to the irritating influence of the 
fire, whilst the patient also has a blood current charged 
with retained excreta, in consequence of inefiicient bowel 
and kidney action ; lupus in a scrofulous subject ; tinea 
tonsurans in a boy with persistent ansemia and a phthisical 
tendency ; pruritus in connection with senile atrophy of the 
skin, liver derangement, gout, i^r it may be in connection 
with diabetes. Such examples might be multiplied almost 
indefinitely. 

In estimating, therefore, the cause of any given cutaneous 
disease, attention must not only be paid to predisposing 
and exciting causes, but to coincident occurrences and ac- 
cidental concomitants which modify such disorder; for it 
is not in the abstract that the disease is to be regarded, but 
in its entirety and in all its clinical features and behaviors. 
The correct estimation of a disease after this fashion con- 
stitutes the true diagnosis, upon which a few remarks will 
be made in the next Section. 



DIAGNOSIS. 41 



SECTION Y. 

DIAGNOSIS. 

First. — In making a diagnosis, the observer should 
apply the rule laid down (Section I.) for examining skin 
diseases — that is to say, he should examine the whole of 
the eruption, and not a part only, and also trace carefully 
its history, to discover the nature of its beginning, the 
character of the primary lesion and its stages, if any, 
and their transitional relationship, and the general course 
of the eruption up to the time of observation. 

Secondly. — He should note the age of the patient, for 
certain diseases, such as tinea tonsurans, are almost pecu- 
liar to childhood ; and others, such as tinea versicolor and 
carcinoma, only occur in the adult ; the sex, because sy- 
cosis, for example, only occurs in the male; the color, 
which is characteristic in lichen ruber, tinea versicolor, 
and syphilis ; the sites of the eruption, the extent of dis- 
tribidion, and the degree of symmetry ; the grou^ying of the 
lesions, whether aggregated, disseminated, in lines or bands, 
in segments or circles, and th^iv mode of spreading; and, 
lastly, whether any special subjective sensations are pres- 
ent, such as itching, tingling, pain, formication, hyper- 
sesthesia, or anaesthesia. The possible effect of the seasons — 
e. g., in prickly heat, and the recent sojurn of a patient in 
the tropics, demand attention. 

Thirdly. — The observer must apply all the facts he 
has collected, and proceed to determine to which class the 
disease belongs, according to the principles laid down in 
the chart in Section HI. It is well in doing so, not only 

4^ 



42 DIAGXOSIS. 

to try and j'ecoguize the particular disease by its own defi- 
nite and special characteristics, but also by the exclusion 

of other affections ^Yith which it is likely to be confounded. 
Is it an eruption of the acute specific diseases? Then the 
constitutional condition will be by far the most pronounced, 
the patient mure or less prostrated, the temperature unus- 
ually high, whilst the other pyrexial symptoms will be 
marked, and out of proportion to the mere rash ; the access 
of the malady will have been comparaiivelij sudden, and so 
on. Is the eruption essentially erythematous? It must be 
one of four conditions — viz.. erythema, intertrigo, roseola, 
urticaiia : and the reader is referred for the feature-s of 
these to the special description in Part II. Is the disorder 
accompanied by sero-purulent discharge, by the develop- 
ment of bull^, by pustules, by vesicles, or by squanic^ 
alone? Then the disease is one of those comprised under 
local inflammations. Is the eruption part of a cachexia, 
or some special diathetic condition present ? Then it be- 
longs to Group 2. And in a similar way may hypertro- 
phies or outgrowths of tissue, atrophies, new formations, 
hemorrhagic spots, neurotic conditions without organic 
changes, pigmentary alterations, parasitic diseases, and affec- 
tions of the glands, hair, and nails, be put under their re- 
spective headings. In the case of new formations, the 
diagnosis is singularly easy. The youngest student can 
readily distinguish the newly formed fleshy mass of a neo- 
plasm in the skin from the ordinary rapidly formed semi- 
hyper^mic inflammatory deposit of a similar size ; and he 
knows practically that he has a case of syphiloderma or 
lupus to deal with. Further, in making a diagnosis, the 
observer must remember to determine whether the disease 
is or is not complicated by another, as evidenced by an 
admixture of diflerent characters, and to thoroughly sift 
oiit the nature of anv constitutional modifvino; influences. 



TREAT M EXT. 43 

Fourthly. — An estimate of the immediate or exciting 
cause of any given eruption is of the first importance in a 
complete diagnosis, l^o doubt, when the observer has been 
able to put the disease before him into its proper class, a 

pretty correct iudication is obtained of its causes, especially 
as regards Class - 1. 2. 4. 5. 6, 9 (Section III.); jet? un- 
fortunately. - ater with the eruptions of 

the conim-i:--: _ . : .:: :i^oe. c^jii^prise'l In Class 3, and with 
those in Classes 7 aL;l 1'.' B and C;. Hciice the observer 
must proceed on the lines laid down in Scori'.n IV.. w^-rk- 
ing out the specifi : : Cr:: ^ :l ::: e r :i u 

of the eruption ir'^iL. ^v,:.^,,:, .;- \vi::_u:. h r:.^ lv/ 
hereditary tendency, the result ''^f VC : C": _:-::::::,, i.-rve 
disturbance, a dispositin in rh ::- - 

on a diseased conditi'jn. '.^r O-i;:.:/::: ::-";::::: C ^,e 
cause to be sought in l-;cal :.^ei:c:r-, :.- r::-\ v_C: C 
(Secti^-n IV.)? And at the sai-^r ::„.7 ::.r : h— rver ^dll 
'^"r: :': ::::nd what has been said aVvu: z'^- :::\d:::dr ehar- 
..:::_ _ ::.- causes of skin dise^i-r-. ^j :.:.- 'kLi_n:-i- will 
be correctly worked cut. The way is now prepared for 
some reroarks on ihera:; ruries in the foilowinor Section. 



a 



SECTION VI. 

TREATMEyj GENERAL PRINCIPLES . 

As there is nothing ess- - pathological 

changes that occur in d : — : d ^ -: lows that 

there is little that is ■. C:d';.:7d: -Crdrd :a :1.7 ::::-*^^]es of 

treatment. The nd;:.__ / .-..:-;: aaa -:::z: .. aa the 

variations of structural detail in the skin — t. o.. hair, sweat, 
and sebaceous glands, nails, and the copious suppr - 

vous, blood, and lymphatic apparatus, and from i 



44 TREATMENT. 

that the skin is an external structure, and so amenable in 
a very large degree to local treatment. 

A correct appreciation of the nature of the morbid pro- 
cess and its cause must precede successful rational treat- 
ment. When, in accordance with the rules laid down, a 
given disease has been placed in its proper clinical class, 
and the exciting and other causes discovered, the proper 
kind of treatment naturally suggests itself. It may be 
said, indeed, that the ten groups of skin diseases require 
three main methods, of treatment — viz., a purely local one, 
or one almost w^holly general, or a mixed one, partly local 
and partly general. A limited number of skin diseases 
have a purely external origin, such as a corn, callosity, 
intertrigo in infants, and the inflammations excited by 
some species of rhus plant, the common stinging nettle, 
croton oil, etc., and these require external remedies only. 
The congenital abnormalities of structure, such as ichthy- 
osis, and blood vascular nsevi, and moles, may be mentioned 
as not amenable to internal treatment. There are also 
some affections caused by external agents which are only 
excited, or only progress, when the tissues are below^ the 
standard of health, such as bricklayers', bakers', or washer- 
women's eczema, and some parasitic diseases, and the ne- 
cessary external treatment requires helping, by suitable 
internal remedies. Here may be mentioned the group of 
diseases having their origin in an innate morbid disposition 
of the tissues, such as rodent ulcer, fibroma, keloid, and 
perhaps lupus, psoriasis, and prurigo, and they are mostly 
unaffected by internal measures, with the notable excep- 
tion of psoriasis, and the latter disease illustrates the fact 
that various stimuli, such as gout, scrofula, climatic in- 
fluences, etc., may excite this morbid predisposition. The 
main treatment of a number of affections consists, with our 
present knowledge, in a tonic or building-up course of 
remedies to rectify widespread lowered nutrition, and espe- 



TREATMENT. 45 

cially with reference to impaired influence of the trophic 
nerves — e. g., in such obscure diseases as scleroderma, mor- 
phoea, lichen planus and ruber, pityriasis rubra, and leuco- 
derma. This brings us to the consideration of such diseases 
as purpura, syphilis, scrofuloderma, gouty eczema, chronic 
urticaria, and some forms of pemphigus, where internal 
treatment is decidedly the effectual method, though ex- 
ternal applications may be more or less valuable adjuncts. 
Finally, such diseases as herpes zoster, roseola, erythema 
multiforme, facial erysipelas, and true impetigo contagiosa, 
tend for the most part, like varicella, to run a definite 
course, and their exciting causes are of temporary char- 
acter, so that these affections get well of their own accord, 
and only require watching to prevent unfavorable inter- 
currences, and the application of external remedies to allay 
pain and irritation, to protect the surface, and dry up dis- 
charge, etc. The majority of diseases, however, run an 
indefinite course, and are to be attacked by therapeutic 
measures based upon a consideration of the varying com- 
bination of exciting, aggravating, or modifying agencies. 
{See Etiology.) The treatment, therefore, consists in a 
careful combination of both local and internal remedies. 

Local remedies are of great importance in skin aflfections, 
and enable us to subdue inflammation, to relieve pain, itch- 
ing, and subjective sensations, to heal the surface, to prevent 
the skin drying up and becoming harsh and uncomfortable 
when the sweat and sebum are not properly secreted, to 
obviate the pain, etc., when the protective epithelium is 
absent, to destroy the harmful character of pus and dis- 
charges, to astringe the bloodvessels, and dry up and stop 
serous effusion, to protect inflamed surfaces from external 
harmful influences, such as air, water, scratching, and so 
on, to stimulate diseased parts to healthier action, to resolve 
eflfusion and infiltration, and to destroy and remove new 
growths. For these purposes, dusting powders, lotions, 



46 TREATMENT. 

liniment applications, ointments, pigments, pastes, baths, 
poultices and fomentations, and cauteries are in use. (^See 
the Cutaneous Pharmacopoeia.) In addition, electricity is 
now called into requisition for remedial purposes. With 
the majority of practitioners, the choice of a remedy is 
mere empiricism. To insure success it is necessary to 
understand what one wants to bring about, and also to 
have a knowledge of the action of the different agents, and 
then make the proper selection. 

Lotions require frequent renewal, unless they are pur- 
posely used for drying up an exuding surface. It cannot 
be too forcibly laid down that an abraded infiltrated skin 
must not be allowed to dry up and crack. The addition 
of oil or glycerine sometimes obviates this. 

Ointments are extremely useful, as they protect inflamed 
surfaces, exclude the air, and lubricate the parts, and form 
an adherent application for the conveyance of various sub- 
stances to the skin ; but they must be carefully prepared 
free from all grittiness and tendency to rancidity.^ Where 
the skin is much inflamed, ointments should not, as a rule, 
be smeared or rubbed on, but be first applied to fine linen 
rag or some soft, unirritating substance. When the effusion 
is free, absorbent antiseptic powders\\Q\^ to dry up the surface 
and disinfect the discharges. If the inflamed surface be 
very extensive, baths are of special service for cleanliness 
and comfort. Hard or sea-water should be avoided. 

A word may be said here as to the danger of " driving 
in " eruptions. In the present state of our knowledge of 
the pathology of disease no fear need be entertained of the 
too rapid alleviation of diseases of the skin. 

1 The numerous hydrocarbons — e. g.^ vaseline, cresoleum, ung. 
petrolei, duroleum, saxoleuni, cosmoline, etc. — now in use as the 
bases of ointments, instead of lard, mark a great improvement in 
the preparation of soothing salves. Collodion, gelatine, etc., may 
be used in some cases. 



TREATMENT. 47 

As regards local remedies, there are some important rules 
to be observed, viz. : 

(1) Whenever active hyperiemia is present, or a part is 
at all actively inflamed, be the disease what it may, appli- 
cations of a stimulating nature should not be used, but the 
treatment should be essentially soothing, otherwise the in- 
flammatory symptoms will be increased, and the disease 
aggravated and probably spread. 

(2) Not until the stage of active hyper^emia has fairly 
passed should stimulating applications or revulsives be em- 
ployed. These are to be reserved for the stages of vascular 
sluggishness and inflammatory induration and thickening. 

(3) The action upon the skin of all external irritants — 
such as scratching — should be prevented, and the air ex- 
cluded from excoriated surfaces, especially by oil-packing 
or the application of a salve. 

(4) All crusts must be carefully removed by bathing, 
poulticing, or oil-packing, before other applications are 
applied. 

(5) It is necessary to remember that many drugs, such 
as mercury, carbolic acid, iodine, tar, pyrogallic and chryso- 
phanic acids, may be absorbed, and therefore they must not 
be applied for too long a time or over very extensive sur- 
faces without careful observation of the urine and general 
efiects. 

As regards internal or general remedies, it is proposed to 
indicate below, in as practical and concise a form as pos- 
sible the conditions which should be taken into considera- 
tion in framing the treatment of such diseases as erythema, 
intertrigo, urticaria, eczema, lichen, prurigo, pemphigus, 
ecthyma, furunculus, pityriasis rubra, and psoriasis ; and 
inflammatory conditions of the glands and hair-follicles, 
such as acne, dysidrosis, and sycosis, which are analogous 
in pathological nature to, and only diflfer in regard to their 
anatomical seat from, those preceding. The following short 



48 TREATMENT. 

sketch or chart, inasmuch as it applies to the great majority 
and most common forms of skin diseases, should be used 
regularly in determining the treatment, which must neces- 
sarily vary with the aifferent combinations of influencing 
agencies referred to. These conditions are: 

Constijxttion. — This causes dyspepsia, liver torpor, reten- 
tion of excreta, vascular fulness and anal congestion, and 
so leads to an impure blood current and debility. It occurs 
in all forms of skin diseases. 

Debility, including anemia. — This retards recovery from 
want of recuperative power in the system ; but frequently 
important emunctory and assimilative organs perform their 
functions languidly or imperfectly as a consequence of the 
debility. It is especially operative in furunculus, eczema, 
psoriasis, lichen, pityriasis rubra, pemphigus, and ecthyma. 

Dyspepsia. — This induces debility. It also leads to liver 
disturbance, and impurities the blood ; and it increases 
hyperaemia by reflex action, as in acne. It is common in 
connection with eczema, urticaria, acne, and sycosis. 

Errors of Diet. — These introduce special irritative sub- 
stances into blood, cause dyspepsia, lead to accumulation 
of nitrogenous matters in the system, to liver disorder, etc., 
and are operative in all forms of inflammatory eruptions 
without exception. 

Gouty and Wieumatic Diatheses. — These cause accumula- 
tion of uric and lactic acids and allied compounds in blood, 
which give an inflammatory character to disease. They 
influence especially eczema, psoriasis, lichen, ecthyma, 
sycosis, and urticaria. 

Diabetes. — This increases inflammatory conditions, favors 
the occurrence of phlegmonous inflammation, leads to freer 
development of disease, and tends to chronicity of eruption. 
Its influence is often seen in eczema, psoriasis, intertrigo 
in adults, furunculus, and anthrax. 



TKEATMENT. 49 

Lack of Hygiene. — This disposes to torpor of skin, and 
the accumulation of epithelial debris and secretion in the 
follicles. It favors the occurrence of morbid action and 
disease, and greatly influences acne, sycosis, eczema, and 
intertrigo. 

Repression of special normal functions (eliminatory and 
otherwise). This throws the necessity of compensatory 
elimination on the skin, w^hich may fail to respond, and so 
become diseased. In dependent parts it leads to increase 
of fluid in tissues. It occurs in furunculus, ecthyma, acne 
rosacea, and eczema. 

detention of Excreta from kidney, liver, and bowel in- 
activity. This, by leading to the accumulation of effete 
products or materies morbi in the blood, gives the latter an 
irritative quality, w'hich aggravates hyperaemia in all in- 
flammatory skin diseases. It is a common cause of pruritus 
of the skin. It also leads, as in the case of kidney inaction, 
to increase of watery fluid in tissues — e. g., in eczema of 
the legs. 

Strumous Diathesis. — This imparts an unusually purulent 
character to effusions, and favors the implication of the 
glands and connective tissues. It operates powerfully and 
frequently in cases of eczema, psoriasis, acne, and sycosis. 
The evidences of struma in advanced life must be carefully 
distinguished from those of gout, and the great tendency 
to pus production in children must not be confounded wdth 
the strumous diathesis. 



PART II. 

THE DESCRIPTION AND TREATMENT OF SKIN 
DISEASES, ALPHABETICALLY ARRANGED. 



Acarus foUiculorum is the name of a mite which 
exists probably as a harmless resident in the sebaceous 
follicles of ahnost all persons, except new-born children. 
They measure 0.085^'' to 0.0125^'^ in length by 0.020'^^ in 
breadth, and lie with their heads directed inwards, and one 
to four are usually found in a follicle, and in various stages 
of development. 

Acne is an inflammation of the sebaceous glands and 
ducts, and of the corium immediately around, and it is pre- 
ceded invariably probably by the retention of altered sebum 
in the form of plugs called comedones, {See Comedo.) The 
disease is seen chiefly on the face and shoulders and chest, 
but may occur on any region where sebaceous glands 
exist. The varieties, or stages, which it is useful to remem- 
ber, are first. Acne papulosa, where the active hypersemia 
present around each follicle has projected it into a red- 
dened papule the size of a millet-seed {Acne simplex), in 
the centre of which the black-topped comedo sometimes 
shows prominently (Acne punctata) ; secondly. Acne pustu- 
losa, where, in the process of maturation of the inflamma- 
tion, a cap of pus forms at the summit of the papulse ; and 
thirdly, Acne indurata, where, in addition to the above 
lesions, we find large livid "boutons" or nodules, formed 
by indolent deep-seated inflammation, which may, however. 



52 DESCRIPTION AND TREATMENT 

go on to suppuration. The name Acne vulgaris is very 
commonly in use also to denote the very frequently seen 
concurrence and admixture of papules and pustules in all 
stages. Some authorities hold that acne is a purely local 
disease following upon the formation of comedo, and due to 
a sluggish, torpid, thick skin ; for the most part, however, 
there are more factors than this in its causation, and the 
occurrence of the eruption about puberty chiefly points, 
not to any special influence of the sexual development, but 
to the general physiological activity of the hair-sacs and 
their appendages at this time, and their predisposition to 
inflammation. Certain it is also that the predisposition is 
often increased at this time by the general debility present, 
whilst the inflammation is lighted up by any gastro-intes- 
tinal derangement, such as constipation, dyspepsia, and 
menstrual troubles. Acne is very common alter variola. 

Bazin and Hebra described also a very peculiar and rare 
form of acne (A. varioliformis) affecting the forehead 
and adjoining portion of the scalp chiefly, in which papulo- 
pustules without comedones form, covered with a very ad- 
herent flat crust, and leave very depressed scars. Some 
think this must be a syphilide. (^See Relapsing Acneiform 
Syphilides.) Hebra further described in cachectic, scrofu- 
lous, and scorbutic persons the occurrence of a general 
acne eruption, without comedo (A cachecticorum), 
which must be distinguished from a miliary pustular syph- 
ilide and variola. 

There is yet another rare affection, occurring chiefly 
about the poll, and described under the names Acne 
Keloidienne or Dermatitis papillaris capillitii. 
It seems to begin in an inflammatory process about the 
hairs, perhaps in the sebaceous glands, and steadily pro- 
gresses from the formation of one or more discrete or con- 
fluent papules, to extensive keloid-like masses, through 
which, here and there, bundles of twisted hairs project. 



OF SKIN DISEASES. 53 

Acneiform eruptions, involving the sebaceous glands, 
may be excited also by various external irritants, such as 
tar, flax, etc., and also by some internal excitants of the 
glands, such as the bromide and iodide of potassium. True 
acne must be very carefully distinguished from the acnei- 
form, and often scarring and ulcerating, syphilide, and 
there is some danger of confounding some slight cases of 
varioloid. 

Treatment. — The objects in view are to get rid of any 
dyspepsia present, and to relieve any constipation by ad- 
justing the diet, correcting bad habits, and administering 
stomachics, sedatives, alkaline and bitter remedies, and 
suitable laxatives. This done, the general strength must 
be built up, and chloro-an^emia corrected by ferruginous 
tonics, by quinine, mineral acids, cod-liver oil, and so on. 
The latter is especially useful in strumous subjects. Mod- 
erate exercise and fresh air are essential, and arsenic is 
sometimes useful in small doses as a tonic. Locally, the 
face in all stages may be thoroughly bathed or steamed 
each night, in the mild forms, for the cleansing and stimu- 
lating effects, and in the inflammatory stages for the sooth- 
ing influence. Where comedones exist, they should be 
expressed if possible. If there be active inflammation 
present, soothing applications must be resorted to, such as 
F. 83, 22, 66 (lotions), 20, 86, 84, 85 (ointments), or 90, 
but, as a rule, stimulant applications are required to pro- 
mote a healthier disposition in the thick, muddy, torpid 
skin. For this purpose, brisk friction with a towel after 
bathing, the use of soaps of properly selected strengths, 
from toilet soaps to medicated or even soft soap, and the 
application of stimulant applications, especially of sulphur, 
are all of the greatest service in different cases. Useful 
applications are seen in F. 44, F. 69, 70, 71, 72, 24, 68, 56, 
58. Active treatment should be carried out at night, and 
then, if the face shows signs of over-irritation, soothing 

5^ 



54 DESCEIPTION AND TREATMENT 

measures may be applied during the day. The strength of 
the application must depend on the character of the skin 
and amount and nature of the eruption present. Occa- 
sionally it is advisable to let out the pus from pustules, and 
to touch some indurated papules with carbolic acid. 

Acne rosacea or Rosacea is a chronic composite 

affection of the face, and particularly of the nose, which is 
generally years in formation, and which is now considered 
a disease distinct from acne. It begins as a frequently re- 
current hypersemia of the face, which gradually gets per- 
sistent with exacerbations, and over this hypersemic area 
papules form in the papillary layer of the skin, and like- 
wise as a complication acne papules and pustules about the 
glands. The persistent hypersemia causes induration of 
the skin, the glands and bloodvessels hypertrophy, and 
dilated venules course over the surface. The nose especially 
reaches gradually an enormous size, with several lobes 
{Rhinopliyma or Acne hypertrojMca). This recurrent hy- 
persemia is largely dependent on chronic dyspepsia, gener- 
ally of an irritative nature, such as is seen for instance in 
hard drinkers ("grog-blossoms"), but it is also associated 
with the plethoric states of middle life and with the climac- 
teric period in women. 

Treatment. — The habits must be regulated, the dys- 
pepsia corrected, the plethora relieved, and all such exciting 
conditions removed, whilst locally it is proper to soothe any 
existent active inflammation, and to briskly stimulate at 
other times (as explained under Acne) to remove chronic 
infiltration. Strong astringents are sometimes useful in 
controlling the vascular dilatation and infiltration of the 
tissues (Krameria ointment, F. 79, and collodion). The 
hypertrophied and -dilated vessels must be destroyed by 
scarification, the lancet, electrolysis, or faradization. 



OF SKIN DISEASES. 65 

Alopecia or Baldness includes all forms of deficiency 
in the quantity of the hair, whether congenital (a very rare 
condition) or acquired, local or general. It is evident that 
acquired alopecia may result either from an excessive falling 
out of hairs, or from a diminished formation of new ones, 
and commencing as mere thinning, it may go on to complete 
baldness. There are two varieties of alopecia which it is 
necessary to distinguish from one another, viz., first, 
Alojjecia senilis, or the baldness of old age; and, secondly, 
a number of cases of premature thinning and baldness 
grouped together as Alojoecia j^Teviatura, Alopecia senilis 
usually commences at the junction of the scalp with the 
forehead, and extends gradually backwards to the vertex, 
and laterally to the middle of the parietal region ; but the 
loss of hair may proceed most rapidly over the vertex. 
The hairs turn gray and drop out, leaving a thinned, 
smooth, shining, bald pate. The conditions disclosed by 
microscopical examination are variable, but in old cases 
the skin structures and glands are generally atrophied. 
Men are aflPected much more than women, and the change 
is incurable. The age at which this kind of baldness sets 
in varies much according to the hereditary predisposition, 
the constitution, etc. Alopecia prematura, or premature 
baldness, signifies that there is excessive falling out, or 
diminished production, occurring independently of the 
natural course of events just described, and it must be due 
to some departure from the standard of health, either of a 
general or local nature. Thus it may be brought about 
from a general lowering of the vital tone, and consequent 
ill-nourishment of existent hairs, and the improper forma- 
tion of new ones — e, g., after exhausting diseases, such as 
fevers, the syphilitic and other cachexise, after the puerperal 
state, during chloro-an^mic states, from fast living, from 
sedentary habits, and so on. Or it may be a direct con- 
sequence of local structural disease, such as morphoea, or 



56 DESCRIPTION AXD TEEATMEXT 

lupus, or of inflammatory affections such as eczema and 
psoriasis, and more particularly of slight forms of sebor- 
rhoea (^A. furfur aced). Lastly, it may be due to a common 
and peculiar form of atrophy of the skin, known as Alopecia 
areata, ^Yhich we must discuss more in detail. Alopecia 
areta vel circumscripta is a very common disease, seen more 
frequently in children than adults, and females than males. 
The subjects of it usually have dark hair and pallid com- 
plexions, and are mostly ill-nourished and lean. The most 
common site is the scalp, especially about the occiput, but 
other hairy parts may be involved, such as the eyebrows, 
eyelashes, beard, whiskers, moustache, axillae, pubes, and 
indeed the whole surface. It usually commences by the 
more or less sudden formation of one or several white, 
smooth, glossy, ivory-like, sharply defined patches, either 
completely bald or studded, especially about the margins, 
w^ith a few club-shaped, broken-oif stumps. The patches 
may extend rapidly or slowly at their periphery and coal- 
esce with others that spring up to form extensive bald areas. 
There is also sometimes seen an acute general falling out in 
which the circular areas are not well marked. An exami- 
nation of the parts proves the existence both of atrophy of 
the skin, and of the hairs and hair-forming parts. The 
loosened hairs are found to have their bulbs characteristic- 
ally w^asted or very ill-formed, whilst the shaft is atrophied 
with the exception of a node, w^hich has been proved to be 
formed originally at a point just above the bulb at the 
very outset of the disease, and it is at this node that the 
hair breaks when it is pushed out of the follicle. Conse- 
quently the hairs are slender at their exit from the follicles, 
and terminate in a club. Ringworm hairs, on the contrary, 
are opaque and swollen as they issue from the follicles. 
In France it has been held that the disease is caused 
by a fungus (^Microsporon Audoinii) far more minute than 
the trichophyton, and liable to be mistaken for fat gran- 



OF SKIN DISEASES. 57 

iiles, but the view is gradually giving way, as observers are 
not agreed as to the character, site, or even constant pres- 
ence of the parasite. There are, on the other hand, many 
reasons to be adduced for the widespread belief that the 
disease is a tropho-neurosis. Ringworm is the only affec- 
tion, with the exception of perhaps morphoea of the frontal 
region, and scar,?, with which it could possibly be con- 
founded, but it should be remembered that in rare cases 
the two diseases may coexist, and that A, areata may be 
seen in more than one member of the same family. The 
ringworm fungus excites more or less inflammation, and 
consequently desquamation, seborrhoea, and discoloration, 
in contrast to the smooth wasted patches of alopecia. 

Treatment. — The local or general causes of the bald- 
ness should be carefully made out, and any seborrhoea, 
eczema, etc., treated by the usual methods. (See those 
diseases.) When the surface is sound the growth of the 
hair may be stimulated by the use of such lotions as F. 94, 
95, 96. The localized atrophied patches of Alopecia areata 
require still stronger application frequently repeated, such 
as iodine liniment, and 97, 98, 99, 100, 101. Blistering at 
intervals with liquor epispasticus is very useful. The 
strength and character of the application must be adjusted 
to the sensitiveness and extent of the diseased area. The 
health must be built up by cod-liver oil, ferruginous tonics, 
quinine, arsenic, and sea air if possible. 

AnaBSthesia may be the result of the direct injury of 
a nerve, or it may supervene on various morbid processes 
involving the cutaneous nerves, such as in syphilis and 
leprosy, morphoea and alopecia, and where a tumor com- 
presses a nerve. It may also be a consequence of lead- 
poisoning, and frequently follows upon functional or organic 
brain or cord disease, and occurs upon the same side as the 
paralysis, or on the opposite side, or is bilateral. 



58 DESCKIPTION AND TREATMENT 

Angioma (a-yyeiovj a vessel.) (See Nsevus.) 

Angioma pigmentosum et atrophicum (xero- 
derma of Hebra) is a very rare affection of the skin of the 
face, neck, hands, forearms, and exceptionally of the legs, 
beginning in early childhood and running its course mostly 
under puberty. The affection consists in the development 
of an immense number of little new capillary formations of 
irregular outline, and mostly very small. These presently 
atrophy, and their site becomes occupied by brown or black 
macules or freckles, and these are succeeded in their turn 
by scar-like atrophy points and spots, which, by their great 
number and aggregation, cause very much disfigurement. 
The affection progresses with very different degrees of 
intensity, and all the stages are seen in active cases coexist- 
ing. A fourth lesion is sometimes seen, viz., little inflam- 
matory growths or tumors made up of an increased number 
of vessels, and these, now and then, apparently give rise to 
epithelioma. The disease has only been met with in Ger- 
many and America until quite recently. 

Anidrosis signifies the diminished formation or absence 
of sweat, and it may be due to a congenital defect or to 
subsequent structural alterations in the skin or glands them- 
selves, in such affections as morphoea and ichthyosis. Sudden 
temporary suppression of the sweat secretion may also occur 
from chills, etc. 

Anthrax or Carbuncle is an inflammation of the 
subcutaneous areolar tissue, which rapidly ends in its 
sloughing with indolent suppuration, the necrosed tissue 
forming many cores over the surface of the circumscribed, 
doughy, and excessively painful swelling, and being dis- 
charged together with scanty purulent fluid, through the 
several corresponding apertures. The surrounding parts 



OF SKIN DISEASES. 59 

are brawny, reddened, and indurated, and the vessels 
plugged. They vary in diameter from one to six inches, 
and occur chiefly about the back and nape of the neck. 
The inflammatory process is altogether more intense than 
in a boil, on a larger scale, and accompanied by far more 
severe general symptoms ; but it is usual to distinguish car- 
buncles from boils by such more or less artificial points as 
the flattened form, the multiple cores, the relatively great 
amount of slough, etc. 

Treatment. — As this affection occurs principally in 
elderly people and in those who are already much debili- 
tated, and as it produces often extreme prostration, every 
means should be adopted to keep up the strength by 
mineral acids — bark, ammonia, quinine, etc., and dieteti- 
cally by port wine, porter, etc. When seated about the 
head of old people, the prognosis is often grave, especially 
if the situation be complicated by the presence of diabetes 
or albuminuria. Locally, the treatment varies in the dif- 
ferent stages. Very early, we may try to check its develop- 
ment (see Furunculus) by painting it, or by rubbing in 
nitrate of silver stick ; later on, it is best to firmly compress 
the walls by strapping and then poultice the summit. If 
later the pain and tension are intense, free incisions give 
great relief, and, on the other hand, the sloughs and dis- 
charges must not be confined for want of an incision. When 
a clean granulating surface is left after the clearance of the 
sloughs, stimulating lotions (lotio rubra of the hospitals) or 
unguents (ung. resin, or one with a little balsam of Peru) 
should be applied. 

Atrophia cutis may exist as an idiopathic change, or 
be secondary to some inflammation or new growth — e. g., 
lupus or syphilis. The skin becomes thin and wasted, and 
so depressed below the surface of any surrounding healthy 
skin, owing to the diminution in size and number of the 



60 DESCKIPTION AND TREATMENT 

elements of the skin; it also loses its natural furrows, and 
becomes smooth and shiny. In the atrophic changes of old 
age (senile atrophy), the loss of the subcutaneous fat causes 
a wrinkled, shrivelled condition. Atrophy of the skin occurs 
also as a conspicuous feature of some affections of the nerves 
— e,g,, after injury or in Alopecia areata. Whether the pecu- 
liar diseases known as scleroderma and morphoea are to be 
considered idiopathic atrophies is still uncertain, but at 
any rate an atrophic process, primary or secondary, is often 
a very important feature, and the same remark applies to 
the affection know^n as linear and macular atrophy, or strict 
et viaculce atrophice cutis , w'hich is very possibly only a phase 
of morphoea ; at any rate, these macules and lanceolate 
stripes sometimes complicate morphoea. Linear atrophy 
occurs as glistening w^hite or pinkish, or livid, depressed, 
smooth or finely reticulated, lanceolate, scar-like streaks or 
bands, very like the marks left by pregnancy, and from 
half an inch to two inches broad by several long. They 
are arranged in groups close to one another in more or less 
parallel curved lines, and they are found most frequently 
near the anterior brim of the pelvis, over the gluteals, and 
on the thighs and arms. Atrophic spots or macules in rare 
cases exist, uncomplicated by the stripes, though similar in 
nature, but have a more or less circular shape, and run up 
to the size of half a crown. A primary red hypersemic 
stage has been described. It is thought that the disease 
may be due to a defect of innervation, but the distribution 
of the patches seldom fits in wdth the course of the cuta- 
neous nerves. These atrophic patches must not be con- 
founded with scars. 

Treatment. — This consists in gentle stimulation of the 
parts by oily liniments, locally and internally, and in pay- 
ing proper regard to the general health. It is a very chronic 
affection and of little consequence. 



OF SKIN DISEASES. 61 

Baker's and Bricklayer's Itch. {See Eczema.) 
Barber's Itch. {See Tiuea sycosis.) 
Bed-bug Eruption. {See Urticaria.) 
Boils. {See Furunculus.) 

Bromidrosis or Osmidrosis signifies a state in which 
the sweat has a peculiarly stinking quality, and it is usually 
associated with hyperidrosis, especially of the feet and axillae- 
Odors of different kinds, and more or less disagreeable, are 
also given forth by the sweat in some nervous disorders, in 
some exanthemata, in acute rheumatism, and in some people 
at the catamenial period, and whilst the bowels are con- 
stipated. The decomposing sweat of some lymphatic and 
red-haired people is also naturally more odoriferous than 
in others. Bromidrosis proper may occur in any class of 
life and in either sex, but is met with frequently in debili- 
tated servants and waiters, and amongst soldiers is often an 
unbearable nuisance. The peculiar penetrating fetor does 
not belong to the issuing sweat, but to the decomposing 
fluid, which soaks into the socks, leather, and clothes, and 
in which bacteria develop. For the local changes set up 
in the skin, see Hyperidrosis. 

Treatment. — The methods of proceeding directed for 
Hyperidrosis are often successful, but where the case is 
obstinate, one of the two following plans may be tried: 
Hebra recommended that the well-washed and dried foot 
should be wrapped accurately in linen spread with dia- 
chylon plaster incorporated with linseed oil. The toes 
must be separated. This dressing should be removed in 
twelve hours, the foot wiped and powdered with starch, and 
the dressing replaced twice daily for eight to twelve days. 
There ought to be a free desquamation of the cuticle. 

6 



62 DESCRIPTION AND TREATMENT 

Ordinary Emplast. plumbi or saponis strapping, renewed 
every two or three days, has been found successful in some 
cases. Dr. Thin suggests a second plan, viz., to soak the 
frequently changed socks in a saturated solution of boracic 
acid before they are again used, and at the same time to 
prevent the saturation of the leather by the use of cork 
soles similarly disinfected each day. 

Canities, or Gray Hair, is commonly seen as one of the 
natural results of advancing age, but the premature loss or 
cessation in the deposition of pigment, may also occur under 
a variety of conditions, as after great mental distress, or from 
debilitated powers after neuralgia, some nerve-lesions, and 
in tufts in leucoderma. The new growth of hair following 
Alopecia areata may be at first without pigment, and there 
are many remarkable facts recorded with regard to heredi- 
tary white tufts, etc. 

Callus, Callositas, or Tylosis, are terms denoting 
the hard, raised, thickened, horny, circumscribed areas of 
skin, caused by constant friction or pressure on particular 
regions, occasioned by various occupations. A callus is 
composed of heaped-up epidermic layers. 

Carcinoina Cutis, or Cancer of the skin. Primary 
scirrhus of the skin is an extremely rare affection, and is 
characterized at an early stage by discrete papules or 
nodules varying in size from a pea upwards. Later they 
coalesce, and the grow^th may infiltrate an extensive surface. 
Scirrhus of the skin, however, is often seen as a secondary 
affection. For the commoner epithelial cancer, see Epithe- 
lioma. 

Carbuncle. (See Anthrax.) 



OF SKIN DISEASES. 63 

Chilblain (Pernio). (See Dermatitis.) 

Chloasma is a term which is still used by some to 
denote Tinea versicolor, but it should be reserved for a spe- 
cial kind of pigment hypertrophy. (See Melanoderma.) 

Chromidrosis is the name given to a very rare condi- 
tion, in which various regions of the body, but especially 
the eyelids, are covered with a line powder of a black, blue, 
brown, or yellow color, supposed to be deposited from the 
sweat by the oxidation of indican excreted with it. Each 
case should be carefully investigated, as the affection is 
sometimes simulated. 

Clavus, or a Corn, resembles a callosity very closely 
in its external features and structurally, i, e., it is a rounded, 
circumscribed thickening of the epidermis, caused by con- 
tinued pressure, only it projects inwards in the shape of an 
inverted cone or " root " to press upon the nerves of the 
derma and cause pain. If situated in a moist situation, 
as between the toes, the epidermic mass may be " soft." 
Inflammation is sometimes set up about corns. 

Condylomata, or " mucous tubercles," are really large 
syphilitic papules altered by the circumstances of the region 
in which they exist. (See Syphilis.) The term Condyloma 
has also been applied to Molluscum contagiosum (C. subcu- 
taneum), and to a variety of acuminate true wart sometimes 
set up by gonorrhoeal discharges, but should be kept for 
these special syphilides. 

Cornu Cutaneum, or the Cutaneous Horn, is a hard, 
dry, outgrowth from the deeper layers of the rete of any 
region, but very commonly from the scalp and face. The 
outgrowth is composed of epidermic cells which have under- 



64 DESCEIPTIOX AXD TREATMENT 

gone the true horny change. They grow with a varying 
degree of rapidity, and may be conical in shape, or becoroe 
variously twisted and distorted. They seldom occur before 
middle-life, and are very rarely multiple. 

Treatment. — Detach the horn and apply caustic to the 
base whence it grew, or excision is perhaps still better. 

Comedones ("black jack," "skin worms") are the 
black-topped accumulations of inspissated oily matter and 
epithelium which plug the ducts of sebaceous glands, and 
almost invariably constitute the first stage of Acne punctata. 
These maggot-like plugs are very often seen disfiguring 
the face especially, but they may occur in any region 
where sebaceous glands exist, and the shoulders and chest 
are most frequently affected after the face. Thick, muddy- 
looking, greasy, torpid, and inactive skins are most favor- 
able to their formation, and they occur chiefly about 
puberty in either sex, though their presence is not to be 
specially associated with the development of the sexual 
organs, but rather with general causes, such as a peculiar 
kind of skin, certain constitutional states, such as the 
lymphatic and strumous diatheses, and with general debility. 

Treatment. (^See Acne.) 

Dandruff. (See Seborrhoea and Pityriasis.) 

Dermatitis is a term which has come extensively into 
use in recent years to denote simple inflammations of the 
skin, which are distinct in their causation from the special 
catarrhal inflammation {eczema), and from the group of 
erytliemata and the exanthemata. It is most important to 
recognize the fact that the dermatitis may present simply 
an inflammatory blush, i. e., be erythematous (and many of 
the eruptions are still grouped with the erytliemata^, or go 
on to a vesicular or bullous or pustular or gangrenous 



OF SKIN DISEASES. 65 

stage, and hence the appearances often agree very closely 
with those of other kinds of inflammation; indeed, we can- 
not separate many, as far as external features go, from 
eczema. The tendency of the skin to inflame, too, is also 
distinctly associated with the general health. The causes 
of dermatitis are infinite, it may be set up by cold — e. g., 
chilblains (erythema pernio), frost-bites ; or by heat — e, g., 
erythema vel eczema solare ; by the prolonged contact and 
rubbing together of secreting folds of skin about the axillse, 
mammsD, abdomen, neck, perineum, especially in infants 
and fat people {intertrigo) ; or by violence, especially by 
scratching; or by contact with various irritating solid, 
liquid, or gaseous substances, such as, in the vegetable 
kingdom, the rhus family, thapsia, mezereon, mustard, 
croton oil, savin, chrysophanic acid ; in the animal kingdom, 
cantharides, the stings of wasps, bees, etc., the burrowing 
of the itch insect {see Scabies), and the biting of lice {Pedi- 
culosis) ; amongst minerals, by arsenical compounds, tartar 
emetic, strong acids, and other caustics. The various 
eruptions due to the internal administration or the absorp- 
tion of drugs are also classed under the term Dermatitis 
medicamentosa, (See Medicinal Eruptions.) 

Treatme^'t. — Where indicated the general health must 
be attended to, and loaded and morbid states of the system 
relieved and the strength toned up. Locally, the operating 
cause (heat, cold, irritants) must be removed or prevented 
acting any further, and as the lesion is an inflammation 
soothing remedies must be applied (F. 20, 22, QQ, 83, 84, 
^b, 86, 90). If the inflammation be caused by a sting or 
an acid, an antacid will give relief. The treatment of 
weeping or chronic infiltrated conditions, is that of eczema. 
The paralyzed condition of the vessels and the bad circu- 
lation in chilblains require stimulation. In intertrigo, the 
surfaces must be kept apart and very clean, and absorbent 
powders applied, and in chronic states very strong as- 

6^^ 



66 DESCRIPTION AND TREATMENT 

tringents (nitrate of silver, tannin, sulphate of zinc, etc.) 
are necessary. 

Dermatalgia is neuralgia of the skin, and is unaccom- 
panied by any structural change. It is mostly symptomatic 
of lesions of the nervous centres. 

Dermatolysis, or Pachydermatocele, is very 
closely allied to Fibroma. By it is designated a general 
hypertrophy of the skin and subcutaneous connective tissue, 
so that soft loose folds, often attaining an enormous size, 
hang pendulous from the region or several regions from 
which they grow. 

Treatment. — Removal by the knife is the only means 
of getting rid of the growths. 

Dysidrosis is the name given to a vesicular disease 
limited very definitely, as a rule, to the pahiis and soles, and 
the sides of the fingers and toes; in addition, however, a few 
vesicles may now and then be present on the dorsal sur- 
faces, whilst a soft red, papular, miliaria-like general erup- 
tion is an occasional complication. At first the parts feel 
hot, swollen, and throbbing, and then discrete transparent 
vesicles, with the deep-seated aspect peculiar to the palms 
and soles, appear in successive crops, and these coalesce 
here and there into small bullae, and these again into larger 
and lal'gor multilocular bullae, simulating a pemphigus. 
The whole epidermis now gets macerated, and peeling ofi* 
discloses a reddened, tender surface, but not a raw, weeping 
one as in eczema. In this manner the afifection runs a 
pretty definite course, usually of two or three weeks, but 
in those who are much debilitated, vesicles may continue to 
appear in a semi-chronic way, and relapses are not infre- 
quent. The subjects of this disease, indeed, are never in 
robust health, and are either notably weakly and out of 



OF SKIN DISEASES. 07 

health, or sufFeriiig from nervous depression. Young 
women, especially those with a nervous temperament, are 
most commonly affected. The disease is more frequent in 
summer than in winter. The exact nature of this affection 
cannot be regarded as settled, for as the name Dysidrosis 
implies, the eruption is considered, on the one hand, to be 
the result of disordered innervation of the sweat glands, so 
that an excessive secretion of sweat altered in quality fails 
to escape properly and collects in vesicles, by which state 
of things some slight inflammation is set up ; whilst others 
hold that it is a localized vesicular eczema from the first; 
and others again that it is a special neurotic affection, sui 
generis. At any rate, the disease should not be confounded 
with the localized vesicular eczema of the backs of the 
hands, in which a few vesicles may appear between the 
fingers, nor with scabies of the fingers, nor with ordinary 
pemphigus localized to the hands. 

Treatment. — This must depend on the view taken of 
the disease. Those who regard it as a sweat disease give at 
first diuretics and mild saline purgatives, and then steadily 
brace up the system by ferruginous tonics, quinine, bark, 
strychnine, etc., according to circumstances. Locally, in 
mild cases, belladonna liniment is useful, but if the attack 
is at all severe it is best to allay pain and macerate the 
thick cuticle by belladonna fomentations, or F. 18, or even 
a few poultices ; and when the sweat is released to apply 
soothing and cooling unguents or lotions (F. 20, 86, 84, 85), 
which should contain a bland oily matter to prevent the 
drying up of the young skin. 

Ecthyma is characterized by the development of one or 
more scattered, isolated, painful pustules, with an inflamed 
areola and hard base, about the size of a fourpenny piece. 
The contents are at first purulent, and afterwards become 
mixed with blood, so that the crusts w^hich are rapidly 



68 DESCRIPTION AND TREATMENT 

formed are thick, large, and dark colored. The pustules 
also have a peculiar shape, for they are not tense and dome- 
shaped as with pemphigus bullae, but flat. As a rule, the 
inflammation is very superficial, and only some pigmenta- 
tion and a temporary scar, if any, is left ; but occasionally, 
in very cachectic subjects, the ulceration beneath the scab 
is unhealthy and deep. Ecthyma is not infrequently seen 
as an idiopathic disease, especially as one or two pustules 
about the knees of children, and is not usually very widely 
distributed, but confined to the extremities or trunk. It is 
also frequently met with as a secondary feature in scabies 
and phthiriasis. It occurs at all ages, and is essentially an 
afifection of the badly nourished and cachectic. Ecthyma 
must not be confounded with the pustules excited by the 
inoculation of pus about unhealthy children, with the 
vesicating chilblains about their fingers, with impetigo con- 
tagiosa of the face and other parts, with the aggregated, 
numerous, and smaller pustules of eczema, and especially 
with the comparatively rare, large, flat pustular syphilo- 
derm, which is a more chronic aflection, and dries into 
large black crusts in layers (rupia) displaying deeper, 
sharply cut, unhealthy ulceration beneath. 

Treatment. — If the ecthyma is secondary to scabies or 
phthiriasis, the parasite must first be destroyed by a mild 
parasiticide (e. g., F. 109, or balsam of Peru), and the de- 
praved constitutional condition met by cod-liver oil and 
tonics. These general remedies, w^ith good food and a stay- 
ing, if possible, of any debauched habits, are necessary in 
idiopathic ecthyma, whilst the eruption is generally easily 
healed by a^pplying a simple astringent salve (F. 52) to 
which a little balsam of Peru may be added after the scabs 
have been removed. In cases where marked ulceration 
exists a few applications of iodide of starch paste (F. 36) 
or iodoform (F. 37) are necessary. 



OF SKIN DISEASES. 69 

Eczema is a usually chronic, sometimes acute, non-con- 
tagious, inflammatory disease of the skin of the catarrhal 
type, with important constitutional relations, accompanied 
by more or less itching and burning, and characterized by 
the formation of either erythema-like patches, papules, 
vesicles, pustules, or fissures, or a succession or mixture of 
all or several of these lesions. Eczema is not to be con- 
founded with the many phases of dermatitis set up by 
various local irritants, such as by lice, the itch insect, dyes, 
cold and heat, etc. (so-called Eczema artifieiale), and closely 
resembling it in the local pathological process, nor w^ith 
other dermal inflammations, such as erythema, erysipelas, 
and pityriasis rubra ; for eczema is nowadays distinguished 
as a specific disease, characterized by a special inflamma- 
tion of the skin, and, as it has been w^ell remarked, these 
inflammations bear no more relation to true eczema than 
the inflammation of a sprained joint to true rheumatism. 
Consequently, we now exclude, amongst other things, the 
so-called grocer's and baker's itch, and lichen planus et 
ruber, and include much of what has been known as im- 
petigo. To thoroughly understand this disease we must 
get rid of the idea that the formation of vesicles is a neces- 
sary or even a very common lesion, and also regard the 
protean lesions as really of secondary consequence ; but, on 
the other hand, we must lay hold of the idea that it is the 
analogue of the catarrh of mucous membranes, and that 
consequently the most conspicuous local feature is the infil- 
tration into the substance of the skin, the exudation of ordi- 
nary inflammatory serous fluid, stiffening and staining linen, 
and its crusting on the surface. This transudation and in- 
filtration of serous fluid causes swelling and thickening of 
the tissues, and a brawny feel, if it does not escape on the 
surface, or if the inflammation be long-continued or wher- 
ever the tissues are lax ; it sometimes collects on the surface 
in vesicles, and more frequently it exudes either after 



70 DESCRIPTION AND TREATMENT 

rupture of the vesicles, or the removal of the cuticle by 
excoriation or otherwise. If the discharge be profuse 
enough it runs away, but if less abundant it dries on as 
crusts, and the latter vary in amount and aspect with the 
admixture of sebum (on the scalp) and epithelial debris, 
of coagulable matter, of blood-cells, and the pus-cells, w^hich 
are especially abundant in children and the scrofulous. 
Even where the skin is not notably thickened, the infiltra- 
tion is show^n by the dirty yellow color left after the blood 
is pressed out of the pai-t. Another very constant symptom 
is disordered sensation, i. e., a burning heat in the acute 
stages, and intolerable itching or incitement to scratch in 
the more chronic cases or later stages. The early mani- 
festation of these disordered sensations is held by some to 
point to primary nerve disturbance, as the later itching is 
due to local interference with the nerve functions by the 
infiltration. The protean eruptive lesions may be referred 
to one of the following categories. First, there may be 
Erythema or congestive redness of the skin in variously sized 
patches, or in a more difi*ased form, and attended by more 
or less infiltration and desquamation (E. erythematosum). 
This constitutes the earliest stage of eczema, and as the sole 
lesion present, perhaps involvingJhe face and neck, is rare. 
Its coarser and most exaggerated phases are nearly allied 
to the scaly areas of a dull-red color, characteristic of a 
declining eczema which has ceased to discharge (E, squamo- 
sum). In these squamous varieties, which may be con- 
foujided with a patch of chronic psoriasis, the dryness and 
infiltration and loss of elasticity cause each movement of 
the part to tear open a painful fissure or crack — e. g., about 
the hands, and to this phase the name E. rimosum velfissum 
has been applied. Secondly, soft red papules, mostly of 
the size of a millet-seed, may be seen either as prominent 
points on an erythematous base, or studded over the surface 
of the skin, and are caused by the special congestion of the 



OF SKIN DISEASES. 7L 

vascular loops and lax structure around the follicles (E. 
paptdosuvi). Many of these papular eczemas were formerly 
called lichens, as was also the case with the papular derma- 
titis set up in washerwomen, bakers, grocers, bricklayers, 
etc. Thirdly, vesicles (jE*. vesiculosum) and pustules (E, 
pustulosum) may form, and they tend to be very closely 
aggregated together, and to very quickly rupture. The 
pustules are of similar formation to the vesicles, only they 
contain more pus-cells, and are often only a later stage of 
the vesicle. It is very essential to recognize this fact clearly, 
because E. jpustulosum, or, as it has been called, E. impetigi- 
nosum or impetiginodes, presents many peculiar features in 
the character of the scabs, etc., and as seen frequently 
about the face and scalp of children, many find a difficulty 
in recognizing it as an eczema. Fourthly, a raw, red, 
weeping surface {E, rubriim vel madidans), dotted over with 
minute red points, is a very common feature, and is often 
seen on the legs, and may result from the confluence and 
rupture of preexisting vesicles or pustules, or frequently 
from the separation of the cuticle by the excessive serous 
exudation. This discharge either dries on the surface into 
crusts, or is thin and abundant enough to run away. There 
are also some secondary features of eczema, which are oc- 
casionally seen, that should be noticed, viz., the hypertrophy 
of a part (e. g., the legs) from very chronic infiltration 
(jE. hypertropMcuiii), and warty overgrowths in old patches 
(^. verrucosum), Now a case of eczema commonly presents 
several of the features just described as successive stages 
in its course ; thus an erythematous condition sets in, which 
is followed by papulation and vesiculation, and is succeeded 
by discharge from a red, raw surface, and crusting, and 
finally desquamation. Or, again, it is not uncommon to see 
several phases side by side, or less frequently any one of 
these several phases may constitute the chief feature, and 
what is commonly only a stage may persist in that phase. 



72 DESCKIPTION AND TREATMENT 

The varieties of eczema have been variously classified 
according to their distribution, configuration, aspect, sus- 
pected cause, and so forth ; but the majority of observers 
now accept the arrangement given above as the most con- 
venient one, although it may be repeated again that the 
conditions denoted by these terms constitute, as a rule, only 
a stage of the eczematous inflammation. Eczema may be, 
more or less, acute or chronic. Really acute eczema is com- 
paratively rare; and as seen about the face, for instance, 
may be ushered in by febrile symptoms and considerable 
malaise. The skin becomes reddened, but, except about 
the eyelids and regions where the tissues are very lax, the 
parts are only moderately swollen. Suddenly vesicles 
evolve with a severe burning sensation, and in about a 
week or ten days the eruption dries up, and the swelling 
and redness gradually subside, leaving more or less desqua- 
mation (or crusting in children) and itching. The attack 
may subside into a chronic condition or present recurrences, 
and this latter feature is very characteristic of some forms 
of eczema. It may occur on any part of the body, but 
especially about the face, genitals, and backs of the hands, 
and is rarely of very wide distribution. 

In subacute eczema, the inflammatory process is less in- 
tense, and the itchy, reddened surface is studded with pap- 
ules, perhaps mixed with vesicles, and scratching gives exit 
to the fluid which infiltrates the tissues. Eczema is far 
more commonly a chronic disease, and it is generally said 
that it does not tend to spontaneous cure ; but one great 
reason for its continuance, besides the persistence of its 
cause, is the incessant scratching, which goes on even during 
sleep, to relieve the intolerable itching which is set up by 
the infiltration. The eczematous inflammation may persist 
in some regions, or recurrent outbreaks may keep up the 
disease. Any of the forms of eczema may be chronic, but 
the vesicular phase is more characteristic of an acute attack, 



OF SKIN DISEASES. 73 

although copious weeping is not an uncommon feature, 
especially from the legs. There are some remarkable feat- 
ures in the distribution to be noticed, for although eczema 
may attack any region, and either be localized to a single 
patch, or, in very rare cases, be quite or almost universal, 
it is essentially a symmetrical disease, and especially attacks 
the flexor surfaces in jDreference to the extensor, the scalp, 
and face of infants, and the face, hands, and forearms, the 
genitals, and legs of adults. It attacks all classes and con- 
ditions of people, and is met with at all ages. In infancy 
eczema is very frequent ; but beyond the existence of some 
special exciting causes, its predilection for certain sites — e,g., 
the head and face, and its pustular character, there is no 
essentially distinctive feature about it. 

With regard to the causation of eczema, it does not ap- 
pear to be hereditary, although certain states, such as gout 
and scrofula, with which it is intimately associated, fre- 
quently are so. Some regard eczema as almost purely a 
local disease of the skin, others as almost wholly of consti- 
tutional origin, and others again, as brought about by a 
combination of these causes. Those who look to its con- 
stitutional origin cannot as yet point out any one definite 
systemic change or state of which eczema is an expression ; 
but they are pretty well agreed that debility, in some form 
or other, underlies the disease, and the lowering of the 
nutrition of the skin giving rise to eczema has been referred 
to three main conditions, viz., a gouty state, struma, and 
neurasthenia. What is meant by the gouty state here is 
rather the continued imperfect assimilation and elaboration 
and suboxidation of the food, and the imperfect removal 
of effete products, either brought about by food improper 
in quality or quantity, or by certain functional derange- 
ments of such organs as the stomach and liver. Active 
gout is only an advanced link in this chain, and the recog- 
nition of the connection of true gout with eczema is very 

7 



74 DESCRIPTION AND TREATMENT 

old. Consequently, in very many cases of eczema, the 
evidence of these conditions is shown in different forms of 
dyspepsia, bowel irregularities, continued excess of lithates, 
uric acid, oxalates, or phosphates in the urine, etc., and this 
is no less true of infants than adults. Struma is another 
cause of the lowered nutrition underlying eczema ; but 
probably this has been so insisted on because of the pus 
formation in the eczema of children, which is not neces- 
sarily due to such a cause, though certain flabby, blue-eyed 
children with fair hair are most subject to the disease. 
Thirdly, it seems clear that eczema is caused by a diminu- 
tion of the normal nerve influence exercised over nutrition, 
which may be conveniently described as nervous debility 
or neurasthenia. This is as yet ill-defined ; but the efiect 
of nervous strain, or excitement, and generally weakened 
nerve power is undoubted. Such cases of eczema in per- 
sons of nervous temperament are frequently recurrent 
throughout life. The connection of asthma and eczema 
has been long noted. Such disturbing causes as worms, 
dentition, uterine troubles, and vaccination, also seem to 
play their part; whilst local venous congestions in the legs, 
anus, and vagina, certainly are favorable to its appearance. 
The diagnosis of such a multiform aflection as eczema 
must be carefully made, both by the recognition of its 
symptoms and by the exclusion of other diseases, because 
all the symptoms noted may occur in other afiections. The 
occurrence of exudation and infiltration at some period of 
the attack, as here described, is, however, very character- 
istic. A brief resume will be here given of diseases likely 
to be confounded, and for further information the reader is 
referred to those diseases. Acute eczema, which is usually 
vesicular or pustular, must be distinguished from the arti- 
ficial inflammations induced by plants, croton oil, poisonous 
dyes, etc., etc., for it has been explained that the patho- 
logical process in the skin is quite similar to that of eczema. 



OF SKIN DISEASES. 75 

These simple inflammations, however, disappear on the re- 
moval of the cause, unless much infiltration has occurred 
from the long continuance of the irritation, and then such 
a patch resembles the squamous variety of eczema. 

In erysipelas, which is accompanied by acute fever and 
constitutional disturbance, there is no surface discharge 
except what collects in the bullae, though there is often 
much infiltration of the skin. Sudaraina and miliaria, 
particularly in rickety infants, might also possibly be mis- 
taken for vesicular or papular eczema ; and dysidrosis of 
the palms especially has to be diagnosed from the recurrent 
form of eczema which chiefly occurs on the extensor sur- 
faces. Scabies is a chronic multiform eruption, constantly 
presenting itself for careful diagnosis ; but, even in the 
absence of cuniculi, the history of contagion, the intense 
itching at night, the sites involved, the absence of infiltra- 
tion, and the usually discrete and non-patchy nature of the 
eruption, will generally decide us. In children, where 
scabies eruption is more patchy, eczema almost invariably 
involves the head. Amongst crustitial eruptions, we may 
mention the pustular inflammation of the scalp and face, 
arising from pediculi (in children especially), impetigo con- 
tagiosa, the crustitial syphilide of hairy parts, which usually 
leaves scarring, and, lastly, sycosis. 

Erythema multiforme is too characteristic to be con- 
founded, and so are the later ringed stages of ringworms ; 
but the early erythematous blotches, and some cases of so- 
called eczema marginatum, can only be distinguished micro- 
scopically. Of itching papular eruptions we may mention 
prurigo, which avoids the great flexures, and is persistent, 
but in old people it is diflficult to diagnose sometimes. The 
chronic characteristic papules of lichen planus may be lost 
in roughened aggregated patches, and so with old chronic 
squamous patches of psoriasis and syphilis, especially 
about the palms of the hands. In doubtful cases the pre- 



76 DESCRIPTION AND TREATMENT 

vious history of eruption must be carefully inquired into. 
The sites occupied by intertrigo are characteristic. Sebor- 
rhoea of the scalp does not weep, but on separating the 
fatty plates, a gray sound surface is usually seen ; on the 
body, the greasy patches of seborrhoea oleosa give more 
trouble. Lastly, we must allude to the great difficulty of 
diagnosing some cases of absolutely universal eruption, 
such as pityriasis rubra, pemphigus foliaceus, eczema, and 
psoriasis ; the latter, however, is only a curiosity. The in- 
tractable so-called Eczema mammae, so frequently associated 
with malignant disease of the breast in women, is probably 
a special kind of inflammation and not a true eczema. 

Treatment. — Eczema is a curable disease tending to 
run through certain stages, and in some cases disappear 
spontaneously ; but in a very great number the disease per- 
sists for weeks, months, or years, by successive attacks or 
a chronic evolution of eruption. In every case it is neces- 
sary to understand about the habits, diet, mode of life, and 
occupation of the patient, the past medical history, and the 
character of the constitution. The treatment must be both 
constitutional and local, for, although it is true that merely 
local measures suit those cases which are tending to disap- 
pear naturally, and such cases as persist after the exciting 
cause has been proved, still, internal medication is decidedly 
called for in the majority of instances. 

General Internal Measures. — The fact should never be 
lost sight of that eczema chiefly attacks the anemic and 
debilitated, and that lowered nutrition is at the bottom of 
it, although it is difficult or impossible to put one's finger 
on the direct cause in every case. Therefore a careful 
search should be made for the existence of imperfect diges- 
tion and assimilation, and a gouty or rheumatic habit, and 
the kidneys and bowels should be watched for any sign of 
deficient or morbid excretion. 

Intemperance in diet, either solid or liquid, or, on the 



OF SKIN DISEASES. 77 

other hand, want of proper food, or the existence of any 
debilitating influence, such as overwork and anxiety, or 
very sedentary habits, must be noted and corrected. The 
bowels must be kept properly open and the flow of the bile 
free, but purgatives, though useful at the outset of an 
attack, or, now and then, as an adjunct to other treatment, 
are debilitating if overdone. In a gouty habit of body, 
with a high-colored urine loaded with lithates, or if there 
is excess of uric acid present, alkaline remedies are some- 
times very useful, such as liquor potassse. 

Diuretics are called for to relieve the skin where the 
weeping is excessive and the tissues swollen, or when the 
urine is scanty, and the alkaline salt, bicarbonate of potash, 
and the neutral acetate of potash, are the best for their 
combined alkaline and diuretic effects. In a somewhat 
different class of cases, the digestion needs strengthening 
by mineral acids, pepsine, bitters, or mild alkalies. But 
these medicines will not, as a rule, effect a cure, and when 
the stomach, liver, and bowels, and the kidneys are all 
acting well, then we must proceed to build up the system 
with cod-liver oil (especially if struma be present), ferru- 
ginous tonics, quinine, strychnine, etc. 

Arsenic is especially useful in chronic cases, particularly 
when the inflammation is dry and scaly. It slioidd not he 
given in acute cases^ and not, as a rule, before the stomach 
and emunctory organs are set in order. In some very 
chronic cases tar and perchloride of mercury have been 
found to exercise a good alterative effect. Change of scene 
and air is often necessary, and at the various Spas this 
change is to be found associated with aj^propriate treat- 
ment in the waters. 

Locally, before we select any application, we must recog- 
nize the stage of the disease, and clearly understand what 
it is we want to do, whether to protect or dry up discharge, 
or soothe the inflammation, or soften up the skin, or astringe 

7^ 



78 DESCRIPTION AND TREATMENT 

the vessels, or stimulate the circulation and resolve the in- 
filtration. Now, eczema is an inflammatory disease, and, 
therefore, in all its acute and subacute phases, soothing 
applications must be used (F. 20, 64, 84, 85, 86, pure vase- 
line, 22, 44, 83, 90). If it is desired to dry up excessive 
discharge, absorbent powders are best, and sometimes a 
lotion is the most convenient application. 

Ointments are indicated in the drier stages, and here the 
necessity for keeping the inflamed skin thoroughly supple 
and prevent it drying up and cracking is to be noted. The 
inflamed skin must be cleansed with soft water or gruel or 
a camel's-hair brush, for sometimes it is so sensitive that 
hard water, soap, and certainly salt water act injuriously. 
The purest glycerine, too, in applications is apt to irritate. 
Crusts should be cleansed away by bathing or by poultices 
before any remedial application is used, and it should be 
borne in mind that the discharge should be disinfected as 
far as possible, and not be allowed to remain and decom- 
pose. The morbid condition often passes aw^ay under sooth- 
ing applications alone, but sometimes mild stimulants (F. 
25, 48,) or astringents (F. 40, 39, 41, 42, 49, 80) are useful 
to restore the tone of the vessels, or stronger ones such as 
F. 31, 73-8, 79, 53-5; F. 52 and 57 are good to dry 
up limited purifluent surfaces as in impetigo contagiosa. 
Strong stimulants and resolvents (68, 62, 75, 74) must be 
brought to bear for the removal of a sluggish chronic infil- 
trated patch. The alleviation of the intolerable itching 
and burning taxes all our resources, and in addition to the 
forms referred to above, F. 18, 65, 93, 23, 26, 29, 30 will 
be of use. Scratching is a powerful agent in keeping up 
eczematous inflammation, and as patients cannot restrain 
themselves, especially children, the surface must be pro- 
tected by linen or thick lint (not by oil silk) on which a 
salve is spread. In extensive cases of eczema, baths are 
very desirable and soothing, taken before going to bed (F. I. 



OF SKIN DISEASES. 79 

a. b. d. e. f.). Opiates and narcotics do little good unless 
sleep is induced, but cannabis indica is of value. (F. 150.) 

Elephantiasis Arabum must not be confounded with 
the totally dissimilar disease, E. Grcecorum or True Leprosy 
(see Lepra arabum). True E. arabum, or " Barbadoes Leg," 
or " Tropical Big Leg," is essentially a disease of tropical 
and subtropical regions ; but a condition clinically indistin- 
guishable from it occurs sporadically all over the world, 
and is at present included with it, although the form seen 
in temperate climes has not yet been proved to have the 
same causation. Further, the term Elephantiasis covers a 
multitude of " giant growths," or hypertrophic conditions, 
mostly resulting from congenital structural defects, viz.. 
Elephantiasis telangiectodes and lymphangiectodes, or ac- 
quired obstructions of the lymphatic system, but also includ- 
ing some cases of chrome phlegmasia dolens, and hypertrophy 
originating in chronic eczema and varicose veins. The disease 
declares itself by an erysipelatoid attack in the limb or part 
affected, w^hich becomes during the febrile attack (" elephan- 
toid fever") reddened, hot, painful, cedematous and brawny, 
and swollen. Eed lines or knotty cords up the limb often 
trace out the inflamed lymphatics, and the related glands 
become swollen and tender, though they may already show 
enlargement. In a few days the constitutional symptoms 
subside, and the local swellings also or not entirely. Again 
and again at uncertain intervals the attacks of lymphan- 
gitis with lymphatic oedema recur, each time leaving some 
additional hypertrophy of the part, so that it gets thickened, 
hard, warty or rugose, with folds, beneath which dirt and 
offensive discharges collect, and hence the comparison to 
the elephant's leg. Thus a scrotum has been known to 
attain a weight of 110 lbs., and reach to the ground, and a 
limb to measure thirty-six inches in circumference. The 
lymphatics may become dilated and varicose, and rupture. 



80 DESCEIPTION AND TREATMENT 

discharging lymph, and foul ulcers may form on the dis- 
eased limbs. The part of the body preeminently attacked 
is the leg, but the hypertrophy may occur in the scrotum, 
penis, labise, and much more rarely in the hands and arms, 
and occasionally in more than one part at a time, as the 
scrotum and leg. 

A variety of the disease affecting the scrotum, and fre- 
quently associated with hsematuria and chyluria, is known 
as " lymph scrotum,'^ " nsevoid elephantiasis," and " varix 
lymphaticus," from the peculiarly varicose condition of the 
lymphatics. The remarkable researches of late years, and 
especially those of Dr. Manson, of Amoy, seem to leave 
little room for doubt that Elephantiasis arabum of tropical 
and subtropical regions and lymph scrotum are only mem- 
bers of a series of " elephantoid diseases," including chy- 
luria, hydrocele, lymphatic abscess and varix, and enlarged 
and varicose glands, and that these are caused by the more 
or less complete blocking of some lymphatic vessel or gland 
either by parent worms or by their embryos. It appears 
that these embryo worms, in an advanced stage of develop- 
ment, are taken into the stomach in drinking-water, bore 
their way into the lymphatic system, and work up-stream 
to find a suitable habitat. There they (probably male and 
female) may live and breed, over many years, countless 
successive progenies of the microscopic worms known as 
Filarice sangidnis hominis, which find their way through 
the glands and lymph-vessels to the blood current. These 
filarise appear in the blood current from sunset to sunrise, 
and in the day are absent, but what becomes of them is not 
well made out as yet. The presence of the parent worms 
may not cause any mischief, because the diameter of the 
embryos allows of their passage through the lymph appar- 
atus ; but if the embryos escape prematurely from the 
mother, and the shell of the ovum be not adjusted in a 
normal manner to form the sheath of the embryos, then 



OF SKIN DISEASES. 81 

the latter cannot pass the glands, but form plugs damming 
back the lymph. The great variety of diseased conditions 
is due to the site and completeness of the obstruction. 
The diseases are, so to speak, a mere accident of the pres- 
ence of the Avorm, for the latter may be undoubtedly 
present for long periods without causing any disease. Ele- 
phantiasis arabum may progress for many years, and is not 
in itself fatal, though complications and intercurrent affec- 
tions supervene frequently on the exhaustion induced by it. 
Treatment. — Very much relief may be afforded by con- 
tinued rest and elevation of the diseased part, by prolonged 
elastic bandaging, and by inunction of resolvent applica- 
tions. Compression and ligature of the main artery of the 
limb have been tried with variable success, and doubtless 
these methods may prove useful in the elephantiasis of 
temperate climes. Now, however, that we know the true 
cause of *' tropical big leg," we must turn our efforts towards 
prevention by systematic careful filtering, boiling, and re- 
filtering the drinking-water w^hence the parasite comes. 
Intractable and unwieldy limbs and scrota should be freely 
removed by the knife. 

Epithelioma (Epithelial Cancer) of the Skin. — The 
Penetrating Epithehoma selects by preference the lips 
(lower lip 90 per cent, of all cases), the scrotum, the penis, 
or about the anus, but it may commence anywhere on the 
surface. It is far oftener seen in the male than the female, 
and is not met wdth, as a rule, until after thirty, and more 
commonly about the age of sixty. The morbid process may 
begin in an obstinate crack or fissure, in an irritable scar, a 
little hypertrophic nodule, a wart, or a mole, and frequently 
takes its rise in some persistently irritated spot. If it com- 
mences as a tender lump — e. g., in the lower lip, it increases 
and gradually ulcerates in the centre, and the ulcer deepens 
and extends to form a more or less rounded ulcer with dirty 



82 DESCRIPTION AND TREATMENT 

foul base, discharging a thin fluid. The base of the ulcer 
may after a time sprout out into a fungus mass, or the 
growth may take on this fungating character from the first, 
or almost the beginning, as about the genitals. After a 
time the glands in immediate connection with the growth 
become implicated, and the disease can no longer be con- 
sidered a local affair. The epithelioma as it extends may 
gradually attack the soft structures, and even the bones, 
but as a rule life is terminated before this occurs, i, e., 
in a few years, either by cachexy, intercurrent affections, 
or secondary deposits. On the back and some other parts, 
however, removed from the orifices of the body, the growth 
has been known to pursue a chronic course for many years. 
About the lips there is an occasional possibility of a syphi- 
litic chancre being taken for an epithelioma, especially as 
in this situation the chancre may be surrounded by a con- 
siderable amount of circumscribed swelling, and the shallow 
ulcer have sloping indurated edges, with a foul, slightly 
discharging base ; and so about the genital regions a " veg- 
etating syphilide " may closely resemble the fungating epi- 
theliomatous growth, but in the former the glands are very 
rarely enlarged. 

The Superficial or Flat Epithelioma is known in 
this country as Rodent Ulcer, and has some remark- 
able clinical characteristics, if not pathological differences. 
First, it is practically confined to the upper tw^o-thirds of 
the face, i, e., above a line drawn from the nostrils to the 
lobes of the ears, though it occasionally appears elsewhere 
on regions removed from the mucous surfaces ; secondly, it 
pursues a remarkably chronic course ; and thirdly, the 
glands are practically never secondarily involved. This 
form also begins in a nodule, or wart, or mole, which gets 
irritable, and is scratched. A tiny scab forms, and is again 
torn off, and so on, but without specially attracting any 



OF SKIN DISEASES. 83 

attention. So matters go on often for years, until the 
nodule attracts notice by its increased irritability and size. 
If left, the growth extends superficially, and more slowly in 
a deep direction, and ulcerates in the centre, leaving a 
smooth base, and hard, almost cartilaginous, whitish, rolled 
edges, w^hich are highly characteristic. So the growth and 
concurrent ulceration extend, destroying soft tissues and 
bone, till life terminates by hemorrhage or intercurrent 
disease. The base of the ulcer occasionally shows more or 
less fungation. Now, whilst mostly considered only a 
variety of epithelial cancer, determined by the site on 
which it arises, some think that it is a different kind of 
growth — e. g., an adenoma of the sweat glands, or that the 
term includes several kinds of semi-malignant growth with 
different origins. A typical Rodent Ulcer, intractable to 
all ordinary healing measures, can hardly be confounded 
with any other disease, except perhaps about the nose with 
an ulcerating syphilide or patch of lupus vulgaris, or a 
chancre. 

Treatment. — The penetrating epithelioma should be 
thoroughly removed before the glands are implicated. 
Under these circumstances freedom from return has been 
experienced certainly for very many years, if not perma- 
nently. The rodent ulcer should be completely removed 
by the knife, or thoroughly destroyed by caustics (F. 5, 7, 
8, 9) or the cautery. 

Erythema is a term which, like eczema, is loosely 
applied even at the present time to a number of affections 
bearing in common the feature of presenting an inflamma- 
tory blush — e, g., the erythematous stage of true eczematous 
inflammation, very slight and early forms of lupus erythe- 
matosus, slight inflammatory eruptions {E. simplex), such 
as the E. Iceve, appearing on distended anasarcous skin, and 
various forms of dermatitis from that produced by a mus- 



84 DESCEIPTION AND TREATMENT 

tard plaster to that set up by the contact of aniline dyes 
{see Dermatitis). The red blush also seen in active hyper- 
semia of the face from dyspepsia, and the passive hyper- 
semia resulting from mechanical obstruction to the passage 
of blood in the legs, are also usually included. Here we 
shall describe under the term Erythema^ only the diseases 
known as E. multiforme (Hebra) and E, nodosum, which 
are characterized by areas of active hypersemia and exuda- 
tion in the tissues, the fluid only in rare instances escaping 
on the surface in the form of vesicles or bullae. Roseola 
and Urticaria may also, for the present at least, be included. 
The four affections form a class by themselves, with the 
characteristics mentioned in the chapter on Classification, 

Erythema multiforme is a non-contagious disease, 
running an acute course, and ushered in usually by general 
malaise, chills, rheumatic symptoms, and some feverishness, 
which is relieved by the outbreak of characteristic red 
inflammatory eruptions of various sizes, but mostly circular 
outline. If the eruption is only a blush, or is very slightly 
raised, it is called a macule, and generally rapidly clears in 
its centre, leaving a ring (E. annulare), or one ring may 
develop within another, and they may present, as they fade, 
a play of colors (E. iris), or coalesce to form patterns (E. 
gyratum). If the border be very well marked and lumpy, 
it is called E. marginatum. Then the inflammation may 
be more concentrated, as it were, into raised papules (E. 
papulatum), or even nodosities, or tubercles (E. tubercu- 
latum), according to the amount of exudation, and such 
papules may be grouped in crescents, but are usually dis- 
crete. Lastly, m rarer cases, the inflammatory exudation 
may terminate in the production of vesicles or bullse (vesi- 
cating erythema). The sites favored are the extensor 
aspects of the hands, and arms, and legs ; but it is seen on 
the face, and no region is exempt. The eruptions last from 



OF SKIN DISEASES. 85 

a few (lays to two or three weeks, and gradually fade away, 
leaviug some desquamation aud pigmentation ; very rarely, 
the eruption is more chronic. Recurrences are met with 
in some cases, and spring and autumn seem specially favor- 
able to the onset of the disease. The term E. multiforme 
is applied because, although the lesions in any given case 
may be all or nearly all of one pattern, very frequently all 
sorts and sizes are mixed. The vesicating forms must not 
be confounded with the vesicular Tinea circinata. 

Erythema nodosum is a very closely allied affec- 
tion, and indeed because of the similarity of the general 
symptoms and the type of inflammatory eruption, and 
because nodose swellings occur now^ and again in E. multi- 
forme, which are indistinguishable from those of E. nodo- 
sum, some authors include the two disorders under one 
head. It is, perhaps, well, however, to separate them, as 
E. nodosum occurs specially in children and young adults, 
does not tend to recur, and, though the eruption may occa- 
sionally be widely distributed, the eruption favors particu- 
larly the legs and sometimes the arms. The eruption is 
ushered in by some general malaise, and is accompanied 
often by considerable constitutional disturbance, and, in- 
deed, in some cases, marked rheumatic symptoms with 
pleurisy, endocarditis, etc. It is almost invariably an 
acute disease, lasting t^vo to four wxeks, occurring in 
weakly persons, and the eruption, which comes out in two 
or three crops, consists of isolated, nodose, painful and 
tender, quasi-boggy, red or livid inflammatory swellings, 
in size from a filbert to a pigeon's egg, or larger. These 
characteristic swellings, which can hardly be explained by 
their occurrence in lax tissue, display, as they fade a\\ay, 
the changes of hue so commonly seen in this class of 
inflammatory eruption. 



86 DESCRIPTION AND TREATMENT 

Treatment. — This consists in rest, and avoidance of 
exposure, and restriction to simple diet. A loaded state of 
the system must be relieved by such remedies as alkaline 
aperients and diuretics, to which some colchicum may 
sometimes be added, and any tendency to constipation 
should be rectified by mild saline aperients, and as soon as 
possible the weakly habit should be remedied by quinine, 
strychnia, iron preparations. Locally soothing, cooling, 
and slightly astringent remedies may be applied, either as 
lotions (F. 15, 18, 22, 44, 8o) or dusting powders (90 et seq.), 
and sometimes warm fomentations, with or without bella- 
donna or poppy-heads, are very grateful. The adoption 
of the recumbent position often affords much relief in E. 
nodosum. 

Erythema gangrsBnosum. (See Gangrene.) 

Favus. (See Tinea favosa.) 

Feigned Eruptions. — It is necessary to be on the 
alert to detect skin affections w^hich have been artificially 
induced or simulated by morbid persons or those desirous 
of exciting sympathy, and especially by hysterical girls. 
Usually, however, suspicions are excited by the chronicity 
of the affection, its bizarre appearance, and its departure 
from the usual types of eruption. We may here point out 
that these simulations, which are of rare occurrence, gener- 
ally take one of the following forms : The eruption is in 
erythematous or excoriated patches, such as may be pro- 
duced by rubbing or by mustard ; or bullous, or pustular, 
or more or less deeply ulcerative, and such as could be 
caused by the application of cantharides, croton oil, or 
some corrosive acid ; or such an eruption as could be 
brought about by the constant and forcible use of the 
finger-nails ; or it is a pigmentation — e. g., simulating chro- 



OF SKIN DISEASES. 87 

midrosis, produced by black-lead, candle-black and grease, 
and other compounds. 

Fibroma, formerly known as Molluscura fibrosum and 
Fibroma molluscum, is an affection of the skin, character- 
ized by hypertrophy and outgrowth of the connective 
tissue from the deeper layers of the coriura or the subcu- 
taneous tissue. As single tumors, growing from the 
shoulder or mammary region, they are not uncommon, and 
then they may attain a very large size, but occasionally 
cases are seen where enormous numbers stud the greater 
part of the surface, especially of the trunk, in every stage 
of development, and with wide diversity of shape and size. 
They commence as little soft protrusions of the skin, and 
as they grow to the size of a pea, nut, orange, or fist, they 
assume various forms, mostly of a rounded or ovoid shape, 
and become pedunculated and pendulous. They are 
covered at first by integument of natural appearance, but 
later the covering skin may become wrinkled or corru- 
gated, or tense and atrophied ; at the same time they may 
acquire a more or less livid or pigmented aspect. They 
grow^ without pain or tenderness, they are freely movable 
with the skin, and in consistence they vary according to 
their size and age, the younger ones being usually soft and 
flabby, and the older ones pretty firm. The course of 
development of each individual tumor is usually very 
chronic, and new ones may appear continuously over many 
years, but sometimes great numbers evolve rapidly. Old 
tumors may ulcerate. Fibroma is seen at all ages, but 
chiefly in adult and middle-life ; in both sexes, and in 
all races, but perhaps, like keloid, it is commoner in the 
dark-skinned. The general health remains unaffected, as 
a rule, but Hebra noticed these subjects were often stunted 
physically and mentally, and the latter point has been fre- 
quently corroborated. Lastly, fibroma has been recorded 



88 DESCRIPTION AND TREATMENT 

in several members, and also in several generations of a 
family. The tumors consist of fibrous tissue in various 
stages of development and condensation, i. 6., the younger 
ones usually consist of young gelatinous connective tissue, 
the older ones have an admixture of denser fibrous tissue, 
and the old ones are composed pretty uniformly of moder- 
ately dense tissue. What part the sebaceous glands play 
in these tumors is not quite clearly determined, for fre- 
quently enormously hypertrophied glands are found deeply 
embedded in the growth, and the dilated openings of the 
ducts are sometimes conspicuous on the surface. It is held 
by some observers also, that these growths arise in constant 
relation w^ith the sheaths of cutaneous and other nerves. 
Fibromata, whether occurring as single or multiple tumors, 
must be distinguished from lipomata, true neuromata, cuta- 
neous cysts, dermatolysis, and elephantiasic growths. 

Treatment. — But little can be done to prevent the evo- 
lution or the growth of the tumors. If any growth be 
inconvenient from its size or situation, it can be removed 
by the knife or by ligature. 

Flea Eruption. — The bites of fleas excite a tiny 
erythematous spot, in the centre of which is a darker red 
hemorrhagic punctum. The erythematous areola soon fades 
away, and the hemorrhagic punctum persists for a time. 
The surface may be covered with an innumerable quantity 
of these spots, and it is not an unknown circumstance that 
purpura or scarlatina has been diagnosed. The flea may 
excite wheals in children. 

Fly Eruptions. — Under this head we will briefly 
refer to the fact that various kinds of winged insects inflict 
bites on the skin, and some occasionally lay their eggs in 
the human skin. Thus, several species of gnats, midges, 
and mosquitos bite the skin to suck blood, and raise in- 



OF SKIN DISEASES. 89 

flamed papules or nodules or buUse, simulating pemphigus 
or herpes iris, or pustules like impetigo. The amount of 
accompanying irritation and inflammation varies much in 
different people. A weak bichloride of mercury or ammo- 
nia solution is a good application, and these insects dislike 
essential oils. In Great Britain rarely, but in South 
America more frequently, the "bot fly" deposits its eggs 
under the skin, and causes the formation of boil-like swell- 
ings of different sizes. The larvse in these cases may wander 
for a considerable distance beneath the skin. 

Fragilitas Crinium is an exceedingly common condi- 
tion of the hair, and the atrophic process which gives rise 
to it, though the exact modus operandi is not as yet deter- 
mined, brings about several varieties. Thus the term may 
be taken to include inequalities in the shaft of the hair, 
and these may occur at very regular intervals, also the dis- 
position of the hair to split up at the free ends ; and lastly, 
a condition known more particularly as trichorexis nodosa. 
In the latter case, the hairs of the face, axillse, pubic re- 
gion, or scalp — and it is of very frequent occurrence — are 
seen to present in their course little swellings, often of a 
white aspect, and suspected to be " nits." When examined 
under the microscope, these nodes are seen to be caused by 
the splitting and fraying out of the fibres of the hair at 
certain points, so that their ends interlock like two besoms 
pressed together end to end. The whole length of a hair 
may be studded with such nodes, and the hair readily breaks 
at these points. In very marked cases the hair becomes 
much entangled. The condition is met with at all ages, 
and is apparently due to intermittent and imperfect forma- 
tion and conversion of the cells going to form the hair. 

Treatment. — It is extremely difficult to cure, and 
shaving, where possible, seems to be the best thing to do. 



90 DESCRIPTION AND TREATMENT 

Mildly stimulating applications (F. 52) appear to do good 
in some cases. 

FrambCBSia (framboise, a raspberry), or Yaws (an 
African word with a similar signification), or Plan (French 
West Indian Colonies), is a contagious, non-hereditary dis- 
ease, siii geveris, distinguished by a special history and very 
characteristic eruption ; endemic, as far as present knowl- 
edge goes, in some of the West Indian Islands, especially 
Dominica ; in parts of Brazil, and parts of the Spanish 
South American Colonies (" bubas"); in some valleys of 
the Peruvian Andes (" verrugas ") ; in the Fiji ("coko") 
and Loyalty Islands, New Caledonia, and other Melanesian 
Isles; in Ceylon (" paranghi disease," from ferenghi, mean- 
ing foreign), and along the Coromandel Coast, in the East 
Indies, in the Moluccas, and in Africa, on the West Coast, 
about Sierra Leone, etc., and on the East Coast, along the 
shores and in the islands of the Mozambique Channel. It 
prevails especially amongst the blacks, but is seen also in 
colored races, and rarely in whites who have lived in 
intimate contact with those affected. Its cause is not defi- 
nitely determined, but the weight of testimony goes to show 
that it does not arise de novo from bad water, faulty diet, 
or insanitary conditions, but that every case is contracted 
by the inoculation of a specific viris from an antecedent 
case, through some wound or abrasion of the skin, however 
slight. After inoculation, the site may heal or take on 
morbid action, and after an incubation period of one to ten 
weeks (minimum period one or two weeks, Nicholls), the 
characteristic eruption appears, but this is preceded, accord- 
ing to some, by febricula, pains in the joints, and a more 
or less general harsh condition of the skin with brawny 
desquamation, which may be temporary or persist. 

The eruption appears as pin-head sized papules, which 
gradually enlarge to the size of small peas, and split the 



OF SKIN DISEASES. 91 

covering epidermis into segments, disclosing a central, 
yellowish, softened point. As the papules continue to en- 
large and mature, and the central softening portion extends, 
the viscid secretion, which has a characteristic odor, incrusts 
on the surface of the more or less rounded flattened mass, 
and the crusts gradually drying, deepen in color. These 
eruptions may attain the size of the palm of the hand in 
some instances, and are rarely painful. If the crusts be 
detached either afoul ulcer is disclosed, or the characteristic 
fungating surface, whence the name framboesia was derived. 
Dr. Nicholls lays much stress on the crusts in the early 
stages, but in old-standing eruptions they may be absent. 
The appearances, no doubt, are multiform, and differ in 
various countries under conditions of chronicity, age, and 
health of patient, climate, sanitation, neglect, and so on. 
Dr. Nicholls says that many evolving papules abort, mostly 
as the disease is declining, and then both small papules and 
scaly patches may be seen. In favorable cases the eruption 
shrivels away, and the crusts dry up and become detached 
in a w^eek or ten days (Mcholls), leaving a macule of 
variable duration. In unfavorable cases ulceration of 
varying degrees of severity may set in. The eruption 
evolves in successive crops, and Dr. Nicholls, in Dominica, 
finds that the disease lasts from one to sixteen months, but 
cases have been known to last several years. The eruption 
is usually discrete, but sometimes becomes confluent or is 
crescentic, and may encircle the mouth or anus like con- 
dylomata, which in these situations it much resembles. 
The sites chiefly affected are the lower extremities, the face, 
the upper extremities, and then the trunk and perineum 
and genitals. With care, yaw^s should not be confounded 
wnth any other disease, although the resemblance, at first, 
to rupia, condylomata, and vegetating syphilides, is close in 
some instances. 



92 DESCRIPTION AND TREATMENT 

Treatment. — In ordinary cases, where the general 
health is good, the disease runs its natural mild course 
under proper food and hygiene, and the prognosis is most 
favorable. Dr. Nicholls is of opinion that in such cases 
"the disease may be arrested, or its duration abridged, by 
the administration of certain drugs." He recommends 
sulphide of calcium, or sulphur and cream of tartar until 
the crusts commence to fall, and then substitutes iodide of 
potassium. In some chronic cases arsenic is useful. In 
cachectic patients the first thing to do is to build up the 
system by good hygiene, nourishing diet, and tonic remedies. 
Mercury, the stock remedy hitherto, seems useless, and 
often is most deleterious. Locally, carbolic oil and lotion 
are the best remedies, with poultices to remove foul crusts. 
Ulcers can be dressed by the usual methods, and skin graft- 
ing is most useful. The iodide of starch paste ought to be 
valuable for foul ulcers. 

Freckles, {See Lentigo.) 

Purunculus, or Furuncle, or the Common Boil, 

is a rounded, painful, circumscribed inflammation of the 
skin, having its seat more or less deeply in the connective 
tissue. A boil begins as a red and tender, tense, rounded 
lump in the skin, and as it becomes more projected has an 
indurated and inflamed base, and slow suppuration super- 
venes in the central portion, which presently sloughs out 
and constitutes the characteristic " core." Rarely, gan- 
grenous inflammation may occur. If the inflammation 
does not go on to suppuration, the boil is called a " blind " 
one. The exact anatomical seat of boils probably varies, 
in the majority of cases it is generally about a hair or its 
sebaceous glands {follicular boils) ; in other cases possibly 
about a sweat coil (see Hydro-adentis) ; and in others again 
in the connective tissue, and apart from any gland {cellular 



OF SKIN DISEASES. 93 

tiss^ie boils). Boils are mostly found on the back of the 
neck, the buttocks, and the limbs, and they may occur in 
considerable numbers, and one after the other over a long 
period of time. They occur in those whose vitality is de- 
pressed by defective or depraved living, or by constitu- 
tional causes, such as scrofula; and again in those whose 
blood current is charged with imperfectly assimilated nitro- 
genous material or with waste products, and particularly 
in diabetics. In such subjects, the inflammation often 
originates in the congestion or blocking up of a duct or 
gland. Further, local irritants may excite their formation, 
and they may accompany diseases in which scratching is 
freely practised — e. g., scabies, phthiriasis, eczema, and pru- 
rigo. Lastly, boils apparently may be epidemic, often at 
the same time as erysipelas, and doubtless from the preva- 
lence of some common deteriorating influence. They have 
been attributed to impure drinking-water. For Delhi boil, 
Aleppo boil, Algerian boil, etc., see Ulcus orientalis. 

Treatment. — We must carefully unravel the under- 
lying cause, and seek out how far deficient assimilation, 
excretion, or improper alimentation is at fault, or whether 
the boils are due to mere debility. In some cases accord- 
ingly the digestion needs helping by pepsin, or putting 
right by antacids and bitters or the mineral acids, or the 
liver must be stimulated and the system unloaded, or ex- 
cretion aided. Afterwards, or from the first in many cases, 
a careful course of aperient ferruginous tonics, cod-liver 
oil, arsenic, red wines, or stout, will be necessary. Locally, 
we may endeavor to abort the inflammation by painting on 
collodion, tincture of iodine, perchloride of iron, glycerine 
of belladonna, and so on, or by adjusted thick, soft plaster 
spread with emplast. opii; but should these means prove 
unsuccessful it is well to poultice thoroughly and relieve 
pain and hasten maturation. Boils should always be pro- 



94 DESCRIPTION AND TREATMENT 

tected from rubbing, and this is easily done by applying a 
covering something like a corn plaster. 

Gangrene of the Skin. — We shall not describe here 
the diffuse gangrene of the extremities, etc., described in 
surgical works, in which the skin is involved with the rest 
of the tissues, nor do more than allude to the rare cases of 
circumscribed gangrene supervening in cachectic subjects, 
especially children, in the course of various eruptions or 
inflammations — e. g., vaccination, ecthyma, pemphigus (P. 
gangrcenosa vel ritpia escharotica), varicella (F. gangrcenosa), 
or herpes (jff. gangrcenosa). Superficial gangrenous patches 
are said to occur also about the extremities in that rare 
vascular affection known as Renaut's disease. But there 
is a rare and remarkable idiopathic affection, characterized 
by tolerable symmetry, and the successive eruption of cir- 
cumscribed, isolated, and superficial' patches, occurring 
sometimes in cachectic subjects, but generally in girls who 
present no other clue to its cause than perhaps a neurotic 
history. The patches range in size up to that of the palm 
of the hand, are often widely distributed, and may occur 
anyw^here. The patches in this affection, which has been 
variously called Erythema gangrcenosum, Dermatitis gan- 
grcenosa, etc., commence by pricking and tingling sensa- 
tions, and the successive formation of either purpuric or 
erythematous, more or less rounded areas, w^hich become 
ansesthetic. In the centre of this area the skin becomes 
mummified, or the seat of a dirty greenish slough, and this 
may be preceded or not by a more or less perfect bulla. 
When the dead skin separates an ulcerated surface is dis- 
closed, and a cicatrix forms and sensation returns. Patch 
may succeed patch in this way for months, and the degree 
of inflammation may vary from an erythema and a bulla 
to severe gangrene. In any given case, however, the de- 
gree of inflammation is fairly constant. Malingering 



OF SKIN DISEASES. 95 

should be carefully excluded in making the diagnosis, but 
there is much difference of opinion as to the genuine char- 
acter of any of these cases. {See Feigned Diseases.) 

Treatment. — Those who consider this affection genuine 
find it very intractable to internal drug treatment, and the 
best course seems to be to build up the health in every way, 
by cod-liver oil, tonics, arsenic, residence at the seaside, and 
so on. Locally, the sloughs should be removed by poultices, 
and the sores usually heal readily under the ordinary 
dressings. 

Grocer's *'Itch" is a dermatitis caused by the irritant 
action of sugar about the hands. {See Dermatitis.) 

Guinea or Medina Worm Disease is an endemic 
disease on the central part of the west coast of Africa, 
about the Red Sea and Persian Gulf, some parts of Western 
Asia, many parts of India, Southern China, and some East 
Indian Isles, and it is of exceptional occurrence in this 
country as an importation. It is capricious in its distribu- 
tion, and variable from year to year even in the above 
countries. It has been made out that the perfect larv^ 
enter the human stomach in drinking-water, and the im- 
pregnated females find their way (the adult males are un- 
known) to the subcutaneous tissues, where they develop for 
twelve to fifteen months w^ithout causing any noticeable ill- 
eflPects, till they attain a length of from six to forty-eight 
inches or more, and come to resemble a piece of stout white 
whipcord. When the time of their maturity and approach- 
ing death arrives, they get restless and seek to escape into 
another medium to discharge their innumerable young. 
The latter are found in fresh water as parasites in certain 
Entromostraca (cyclops). There is nothing special about 
the fresh water in which they may be found, but it has 
been noticed in India that cases present themselves increas- 



96 DESCRIPTION AND TREATMENT 

ingly with the hot season, reach their maximum number in 
July and August, and decline with the monsoon. The 
symptoms arise when the worm grows restless and seeks to 
escape, and there are violent itching and pricking, pain, 
stiffness, and a boil-like or bullous inflammation at the spot 
where the worm pierces the skin. The site of exit is in 
ninety-nine per cent, in the lower extremities, and the foot 
and ankle are specially selected, but the worm may issue 
from the scrotum, back, or elsewhere. 

Treatment. — The most approved method is to secure 
the head to a quill with thread, and several times daily 
with the gentlest traction gradually wind out the worm on 
the quill, the parts meanwhile being kept moist by poultices 
of glycerine and water applications. If the worm is not 
firmly secured, it recedes and migrates about the body. 
Assafoetida is recommended for internal administration. 

Gutta rosacea, or Rosacea. {See Acne rosacea.) 

Haematidrosis {Ephidrosis cruenta, Sudor cruentus), 
or the " bloody sweat," consists in the escape of blood cor- 
puscles on the surface of the body wath the sweat, without 
breach of continuity of the skin, and it is undoubtedly of 
very rare occurrence, though w^ell-authenticated cases are 
on record. It should be distinguished probably from the 
class of cases due to vicarious menstruation, where blood 
exudes from the surface of erythematous areas of skin. 
Hsematidrosis is often associated with profound nervous 
derangement or prostration. 

Hair, Diseases of the, — We have alluded in other 
places to the structural diseases of the hair caused by the 
trichophyton fungus, that brought about in alopecia areata, 
trichorexis nodosa, and fragilitas crinium (see the latter). 
It is necessary to mention further the falling and atrophy 



OF SKIN DISEASES. 97 

of the hair in such cachectic states as syphilis and new 
growths (lupus), and inflammations (seborrhoea, eczema). 
Another curious condition (Wilson's Leptothrix) is one 
mostly found on the axillary and pubic hairs, but also be- 
neath the nostrils. Here the cuticle flakes off*, and a few 
fibres fray out, perhaps the whole length of the hair, per- 
haps only here and there. These frayings collect fatty and 
other foreign matter, and in this a minute fungus develops. 

Herpes is a non-contagious disease, characterized by 
the eruption of vesicles, as a rule rather larger than those 
of eczema, mostly arranged in one or more clusters on 
erythematous bases, of the size of a sixpence to a five- 
shilling piece. This eruption runs a very definite course 
of from one to two or three weeks, and the clear contents 
of the vesicles become cloudy, ard, if uninjured, the walls 
shrivel and finally subside to form a thin flake. The vesicles 
are formed by the exudation of serum and leucocytes into 
the papillary layer and rete mucosum, and its encasement 
in loculi formed by the stretched-out rete cells. Herpes 
may be subdivided into two groups, viz., Herpes facialis et 
progenitalis and H. zoster. 

Herpes facialis, which is very common, occurs on 
the face. All are familiar with the outbreak of one or 
more clusters of vesicles on the lips (H. labialis), which 
recurs over and over again, with every little derangement 
of the health apparently ; but more rarely the eruption is 
more widespread, and extends over the cheeks, on to the 
ears, or even to the buccal mucous membrane, the pharynx, 
and inside of the nose. This form occurs in connection 
with pneumonia, catarrhs of the air-passages, the crises of 
fevers, etc., and hence is said to be symptomatic. It is 
probably due to reflex nervous action following these 
special shocks to the nervous system. 



98 DESCKIPTION AND TREATMENT 

Herpes progenitalis is a very closely allied phase, 
and consists in the evolution of a little group of vesicles 
about the prepuce, or some other part of the penis, or on 
the external genitals of the female, in whom, however, it 
is but rarely observed. From the nature of the site on the 
prepuce or glands, the vesicles have an imperfect and 
ephemeral existence, as in the mouth, and only a number 
of little erosions are usually observed, which quickly heal, 
but may be mistaken for chancroids. There is a similar 
tendency to recurrence, and a similar predilection to occur 
in young adults, though it may occur at any age, as in H. 
labialis. The eruption is supposed to be excited in certain 
neuropathic subjects by acid states of the system, by worms, 
by dyspepsia, etc., and such causes must be rectified to pre- 
vent its recurrence. 

Herpes zoster, Zona, or Shingles, differs from 

the foregoing in that it only exceptionally occurs more than 
once in the same subject, and the eruption is distributed in 
marked relation to the course of cutaneous nerves, and is 
by other symptoms demonstrated as dependent on a nerve 
lesion. The type of this phase occurs as groups of vesicles 
clustered on erythematous bases, arranged in the course of 
the terminal twigs of the intercostal nerves, and forming a 
semi-girdle round the trunk. This eruption may, however, 
occur in the course of any cutaneous nerve, and striking in- 
stances are afforded in its not uncommon outbreak over the 
distribution of the first division of the fifth nerve (H. zoster 
ophthalmicus vel frontalis), when it covers the forehead and 
part of the scalp in a fan-like arrangement, and is asso- 
ciated often with conjunctivitis, keratitis, iritis, etc.; or, 
again, more rarely over the distribution of the second and 
third dorsal nerves and their intercosto-humeral branch, or 
down the leg. Besides the frequent occurrence of neuralgia 
before or after the eruption, hyper^esthesia, ansesthesia, 



OF SKIN DISEASES. 99 

paresis, amyotrophy, etc., sometimes exist. It has been re- 
corded on very rare occasions, in the course of cerebral 
lesions, and rather more frequently in cord lesions, as mye- 
litis and locomotor ataxia, but most commonly it is of 
peripheric origin, either arising spontaneously, apparently 
from general gouty or rheumatic conditions or local in- 
flammation, or it is asserted during the exhibition of arsenic, 
or apparently from reflex action following injury to some 
nerve in another part, or from pressure or irritation of a 
nerve by an aneurism, tumor, or carious vertebra. Patho- 
logically, its neurotic origin has been demonstrated in 
several cases by the proof, post-mortem, of congestion and 
neuritis, sometimes in the ganglia, sometimes in the 
periphery of the nerve beyond the spinal ganglia, and also 
in the posterior spinal roots. In Herpes zoster the clusters 
of eruption come out successively over one or two days, 
and run a very definite course of from two to four weeks. 
Chronic herpes is a curiosity, and is due to an irritable scar 
or some other persisting irritation. It is rare for more than 
one nerve to be aflected at the same time (except one or 
two adjoining each other on the same side). It occurs 
equally on either side, and is said to be more frequent in 
spring and autumn. It is met with at all ages, and is often 
associated with marked constitutional disturbance, and in 
elderly people, followed by much exhaustion. 

It is necessary to be aware also of the fact that the term 
General Herpes has been applied to some rare widespread 
and mostly acute eruptions of large vesicles or small bull^, 
though their exact relation to Herpes zoster and pemphigus 
is as yet ill-defined. 

Treatment. — As a rule, all that is necessary to be done 
is to soothe any irritation, or dry up any fluid by the dust- 
ing on of powders (F. 90, et seq.), or the use of bland salves 
or lotions (F. 20, 40, 47, 86, 84, 85, and 83), whilst the 
eruption is protected by a covering of thick muslin or 



100 DESCRIPTION AND TREATMENT 

cotton-wool. If much pain is present whilst the eruption 
is out, such applications as amyl colloid (F. 34), painted on, 
may be of service, or opiates on spongiopiline, or bella- 
donna fomentations (gr. xx of the extract to aq. gij), or 
poultices, whilst if the neuralgia persists, sedative hypo- 
dermatic injections may be necessary. Internally, it is 
necessary to carefully counteract any febrile, dyspeptic, 
rheumatic, or gouty conditions, and to support the general 
health by red wine, bark, etc., where necessary. Some 
physicians try to cut short the eruption by phosphide of 
zinc, etc. 

Herpes iris (Willan and Bateman) is a rare and strik- 
ing affection which, though called a herpes, has the closest 
relation with the ringed and papulate forms of erythema 
multiforme; indeed, it is regarded by some as only an out- 
lying member of the E. multiforme group. The affection 
occurs in weakly subjects, runs a course of two to four 
weeks, and is mostly ushered in and accompanied by some 
malaise. The eruptive lesions come out in several crops, 
and begin as erythematous papules, the size of split peas, 
isolated and situated about the hands, especially the backs, 
or in addition about the forearms, knees, and insteps, and, 
as the exception, many may remain at the papular stage. 
Generally, how^ever, the papule becomes capped with fluid, 
and as the inflammation extends to a very limited extent, 
the central cap may become surrounded by a secondary 
ring of vesicles, or rarely by a second and a third ring, one 
within the other, the whole soon displaying the rainbow 
tints, whence the affection derives its name. The lesions 
may coalesce, the contents may become purulent, crusting 
ensues, and scars are often left. The affection occurs in 
young people mostly, and, like erythema multiforme, is 
symmetrical, and tends to recur. There may be itching 
and burning, but no marked distribution along the course 



1 



OF SKIN DISEASES. 101 

of the cutaneous nerves, nor is there any neuralgic pain. 
The eruption is, however, frequently associated with Herpes 
facialis, which may extensively implicate the buccal and 
nasal mucous membranes, and rarely with Herpes pro- 
genitalis. 

Treatment. — In the early stages, a soothing lotion (22, 
83) or dusting powder (90, et seq.) may be applied, but 
later the contents of vesicles should be let out, and where 
crusts form they must be bathed off, and a simple healing 
or slightly astringent salve applied (F. 20, 25, 40, 42, 84, 
85, SQ). Internally, the general treatment must be directed, 
in the first instance, against any dyspeptic or rheumatic 
symptoms, and the building up of the general health by 
tonics must be attended to in order to prevent recurrence. 

Hydroa is an old term which had fallen into disuse 
until Bazin revived it to denote certain rare vesicular 
eruptions, one variety of which {H. vesiculeux) he after- 
wards acknowledged to be the Herpes iris of Willan and 
Bateman. However, the name is still applied by some to 
a heterogenous group of rare or anomalous vesicular or 
bullous eruptions, which would rather seem to fall under 
vesicating erythema multiforme, herpes iris, or pemphigus. 
(See also General Herpes.) 

Hydro-adenitis is a term which has been applied to 
furunculoid swellings which are supposed to arise in an in- 
flammation of the sweat glands. They occur chiefly in 
very hot weather, and especially about the axillse. Perhaps 
many of the boils so common in the tropics are of this 
nature. They may be treated like boils. 

Hyperidrosis, or the state in which sweating is pro- 
fuse, or too easily excited, is met with under a variety of 
circumstances. Thus, it may occur during both heightened 



102 DESCRIPTION AND TREATMENT 

and lowered vascular tension, and be caused by emotions, 
by external heat — e. g., tropics and Turkish bath, by dia- 
phoretics, and by perverted innervation, as in the vaso- 
motor paralysis of the sweating stage of ague, etc. The 
influence of the nervous system, indeed, over the occurrence 
of sweating is very marked. It is seen in the course of 
some fevers — e. g., rheumatism, and marks the crises of 
others. The sweats of pyemia, of phthisis, cancer, and 
other debilitating afiections are familiar to most. Besides 
these general sweats, we meet also with abnormal local 
sweatings. Such not infrequently accompany various 
paralyses and interferences with the functions of the nerves. 
We have here to deal, however, with the annoying general 
sweating arising from debility, possibly succeeding a fever, 
and more particularly with the local sweatings of the palms 
or soles, axillae, or genital regions, which cause so much 
annoyance, first, because much discomfort may arise from 
the saturation of the clothes and the chill produced; 
secondly, because the sweat decomposes and excites a 
dermatitis ; and thirdly, because such acrid sweat develops 
a most unbearable odor. (^See Bromidrosis.) 

Treatment. — We have only to deal here with the gen- 
eral or local sweatings arising apart from markedly dis- 
eased states. These are generally associated with more or 
less debility, and must be met by the exhibition of tonics, 
especially the mineral acids, strychnia, etc. Locally, ex- 
treme cleanliness should be exercised, and the parts (if not 
much inflamed) washed once or twice daily with carbolic 
or thymol soap. The hypersecretion may be often much 
arrested by the use of belladonna liniment rubbed into the 
part, or the free application to the parts and in the socks 
of astringent and absorbent powders, such as tannin and 
alum with starch, to which antiseptics may be added to 
prevent decomposition (F. 90, et seq,). Any dermatitis 
excited is to be treated like an eczema, and besides the 



OF SKIN DISEASES. 103 

dusting powders just mentioned, antiseptic and drying 
lotions are useful (F. 83, with salicylic acid), and if the 
corium is much exposed, astringent and bland salves (F. 
20, 25, 78b, S6), 

Hypertrichosis signifies an excessive growth of hair 
either upon regions where hair usually grows or on other 
parts. The congenital hairy mole, or nceviis pilosiis, is an 
example, which is usually associated with extreme develop- 
ment of pigment, and often papillary hypertrophy. Tu- 
bercular children, as is w^ell known, may acquire a notable 
growth of hair on the trunk and limbs. In some persons, 
again, it has but little significance. But apart from this, 
the normally hairy parts and the body and limbs generally 
may become thickly coated with hair, and to a very extra- 
ordinary extent sometimes. Thus, in books on the hair, 
portraits may be noticed of bearded women, and people 
covered with hair like a gorilla. 

Treatment. — ]^o one line of treatment can be laid 
down. Hairy n^evi may sometimes be destroyed by the 
cautery or be excised, or they may be kept shaved, and the 
mark partially hidden by po\vder, or depilatories (F. 102) 
may be used, or epilation in slight cases practised fre- 
quently. After the latter methods, however, the hair 
constantly tends to grow again. Recently, the method of 
destroying the hair papillse one by one by an electrolytic 
needle, has met with increasing favor. 

Ichthyosis is a disease of the skin which presents a 
wide diversity of appearances. It gradually develops in 
tender infancy, or is more rarely actually congenital ; it 
affects the w^hole of the body usually ; it persists through 
life, and is incurable ; is often hereditary, and is character- 
ized by certain structural and functional defects which 
vary in difiTerent cases. The very mildest form is that in 



104 DESCRIPTION AND TREATMENT 

which the external aspect of the arms or thighs is studded 
with a multitude of miliary prominences, due to the plug- 
ging of the follicles by exuviae, and this gives to the surface 
a rough and rasp-like aspect and feel. This condition 
should not be confounded with follicular plugging acquired 
from uncleanliness, nor with the lichen pilaris of strumous 
children. The plugs sometimes project markedly from the 
follicles as little spines. A mild and very common form, 
known as Xeroderma, is the condition in which the skin 
universally is dirty looking, harsh and rough, dry, shiny, 
and tense in some parts, and crinkled or covered with 
branny scales elsewhere. This condition is worse in winter 
than summer, and is liable to become inflamed, and the 
weeping, raw surface may mask the primary disease and 
closely simulate eczema. Between this xeroderma, in which 
the sebaceous, if not the sweat, flow is more or less arrested, 
and the extreme forms of ichthyosis, endless links present 
themselves. First, we see an exaggerated form of xero- 
derma in which the skin is somewhat thickened, and a 
parchment or mother-of-pearl aspect is presented (J. nacree 
vel nitida). Then, in other cases, as the skin is increas- 
ingly thickened, the natural lines and furrows become 
more and more exaggerated and deeper, marking the sur- 
face off* into lozenge-shaped areas, and the scales show a 
disposition to adhere only by their centres (J. simplex). 
With the papillary hypertrophy, also, and the accumula- 
tion of epithelium, much sebum gets mixed up in some 
cases, so that large, dirty, mud-like masses cake on the 
skin and become more or less adherent, being divided up 
by deep fissures, as is often well seen over the front of the 
knees. Lastly, these masses may project as large spines 
and lumps, to which extreme forms the terms J. cornea vel 
hystrix vel hystrieimus have been applied. Such cases are 
often associated with marked mental and physical defi- 
ciency. AH kinds of fanciful resemblances have been 



OF SKIN DISEASES. 105 

suggested, as set forth in the terms " man-fish," " fish-skin 
disease," "porcupine-man," and "serpent-skin." This dis- 
eased condition of skin persists generally through life, and 
up to puberty it may get worse and worse, the masses 
being continually shed and removed. Occasionally ichthy- 
osis is localized, and then, as also in some cases of general 
distribution, the diseased areas may be arranged in lines 
or bands. New ichthyotic areas may be seen gradually to 
develop during childhood. In the general cases there is a 
marked tendency for certain parts* to escape — e, g., the 
flexures of the joints, the genitals, the face, and the palms 
and soles. Lastly, ichthyosis is met with in different de- 
grees of intensity on different parts of one and the same 
patient. 

Ichthyosis can only rarely be confounded with other 
affections, such as a simple, harsh, ill-nourished skin, and 
one thickened by chronic, dry, and nearly universal eczema. 
The localized forms should be distinguished from congen- 
ital warty bands, and a word of caution is necessary with 
regard to a very rare form of seborrhoea, simulating I. 
cornea. 

Treatment. — Though incurable, great amelioration can 
be effected. In the milder forms, the skin should be kept 
systematically softened, especially in winter, with glycerine 
and water, or glycerine of starch. In the more exagger- 
ated forms, two procedures are necessary, one to remove 
the hypertrophied masses by prolonged and incessant bath- 
ing and washing ; and this having been effected, to prevent 
their reaccumulation by a continuance of the same methods, 
or by oil or glycerine inunctions, or by applications, such 
as tar (F. 73), to check the cell-growth. Alkaline baths 
are the most useful for getting off the plates ; but some- 
times a stronger alkaline lotion, kept in prolonged contact 
with the skin under oil silk, is necessary to get off specially 
obstinate masses. 



106 DESCRIPTION AND TREATMENT 

Impetigo, as distinguished from Porrigo, is an old and 
almost disused term, causing much confusion to the student. 
It was formerly applied to a non-contagious eruption of the 
scalp, composed of small, slightly raised pustules, pierced 
or not by hairs, with very little surrrounding inflammation 
and red base, very quickly maturing, discharging, and 
crusting, occurring singly, but mostly in groups, and situ- 
ated chiefly on the scalp of children, and the face of adults, 
but seen also on the trunk and limbs. The majority of 
these cases were undoubtedly phases of pustular eczema. 
Later, a contagious Impetigo capitis, due to lice, was recog- 
nized {see Phthiriasis), and now-a-days at Blackfriars Hos- 
pital there is described an Impetigo vel porrigo contagiosa^ 
distinguished from eczema by the character of the discharge 
and crusts, occurring as flat vesico-pustules about the scalp, 
face, and hands, and drying into yellow friable crusts. It 
may originate, Mr. Hutchinson says, from any cause which 
induces formation of pus — e, g., lice, the suppuration under 
the scab left by vaccination, etc. This pus is inoculable, 
and is contagious to different parts of the skin of the same 
patient and others. The term Impetigo, therefore, as now 
used, is applied both to pustular eczema by some, and to 
the pustular dermatitis set up by irritants, especially by 
lice about the head. (See Phthiriasis capitis.) 

Impetigo contagiosa is an affection described by 
Tilbury Fox as quite distinct from the Porrigo contagiosa 
of the Blackfriars surgeons. It is not yet universally 
recognized as a distinct disease. The eruption occurs 
chiefly about the face, but may extend to the hands, head, 
to the mucous membranes and conjunctivae, and rarely to 
the body, and children only are attacked wdth rare excep- 
tions. The affection is often ushered in by more or less 
malaise and pyrexia, usually, however, of a very slight 
character, and the eruption commences as discrete vesicles? 



OF SKIX DISEASES. 107 

or tiny flattened bullie, which extend peripherally (imlike 
ail eczema vesicle or pustule) to cover the area of a split 
pea, or a threepenny bit, if not broken. As they grow, the 
clear contents become clouded and then purulent, and 
finally dry into yellowish crusts, which look as if they were 
"stuck on." Each vesico-pustule lasts nearly ten days, 
and as all do not evolve simultaneously, the affection may 
persist for several weeks. The lesions are discrete and not 
crowded on a common infiltrated base, but when closely 
set the crusts become confluent and disguise the typical 
character of the eruption ; only in this case can it well be 
confounded with eczema. This affection is now and then 
epidemic in schools, streets, or houses, but is mostly spo- 
radic, and it is not of very common occurrence. 

The inoculability and contagiousness have been ascribed 
to the presence of low vegetable organisms found in the 
contents of the vesico-pustules or in the scabs, but this is a 
debatable matter as yet. The great point in the diagnosis 
is to distinguish it from the very common pustular erup- 
tions set up about the faces of unhealthy children by the 
inoculation of pus from such sources as eczema impetigi- 
nodes of the scalp, the pustular dermatitis of the poll due 
to pediculi, festers from scratches, purulent otorrhoea and 
nasal catarrh, vaccination pustules, etc. 

Treatment. — The lesions are very superficial, and 
locally all that it is necessary to do is remove the scabs by 
oily applications, poultices, or bathing, and then apply, 
night and morning, a weak ammoniated mercury ointment 
(gr. V to vaseline §j). In this respect it contrasts strongly 
with true eczema. In str*Umous subjects there may be slight 
ulcerations. 

Intertrigo, called also Erythema intertrigo and 

Eczema intertrigo. (See Dermatitis.) 
Itch, Army Itch, Malabar Itch. (iSee Scabies.) 



108 DESCRIPTION AND TREATMENT 

Keloid, or Kelis (Alibert's Keloid), is a new growth 
of the connective tissue of the skin, or probably always of 
scar-tissue, commencing as small nodules, or thickenings of 
preexisting scar-tissue, and increasing to form hard, dense, 
elevated, glossy, either circumscribed, rounded, or oval 
tumors or bands, or trabeculated flattened masses of most 
irregular size and shape. From the raised body of the 
growth fibrous bands, brought into prominence by the con- 
tractility of the mass, commonly radiate into the surround- 
ing tissue, and hence the term Keloid, from a fanciful 
resemblance to a crab's claw. The color varies from a pink 
to a darker red, or even livid hue, and rarely there may be 
more or less dark pigmentation. Occasionally uncomfort- 
able sensations are experienced, or even pain, especially on 
pressure. They usually have a very chronic growth, and 
after a time may remain stationary for the rest of life, but 
not uncommonly, especially in the young, they get softer 
and more elastic and gradually disappear ; still the prog- 
nosis in this respect is not very satisfactory. Keloid occurs 
in both sexes, and, as for age, most commonly in early or 
middle life. The shoulders and sternal region are favorite 
sites, but the growths may be seen anywhere on the skin. 
Commonly they occur singly, sometimes there are two or 
three distinct masses, and occasionally they are very exten- 
sively distributed, and more or less symmetrically placed. 
It is usual to describe two varieties — the true, spontaneous, 
or idiopathic keloid, which arises from the previously healthy 
corium perhaps after some irritation, and the false or trau- 
matic, or the keloid of cicatrices. It is probable, however, 
that the hypertrophic outgrowth never arises otherwise 
than in a preexistiug cicatrix, such as results from vaccina- 
tion, acne, smallpox, varicella, syphilis, burns, ear-borings, 
floggings, etc. Still it is well known that the members of 
particular families are specially predisposed to keloid, and 
that dark-skinned races are more subject to its occurrence 



OF SKIN DISEASES. 109 

than the fair-skinned. The tumors consist of densely felted 
connective tissue, with a varying but small proportion of 
cell infiltration in the different cases about the vessels, and 
these growths can hardly be confounded with any other 
disease. Dr. Liveing insists on the structural and other 
differences between cicatricial keloid and a hypertrojyhied scar, 
though it is confessedly difficult in many cases to distin- 
guish the two by the unaided eye. The dense and but 
little vascular keloid tissue grows up in the looser and 
more vascular scar-tissue, and, unlike simple hypertrophy 
of the latter, pushes it aside and invades the healthy corium 
around. 

Treatment. — The treatment is unsatisfactory. If re- 
moved by knife or destroyed by caustics, keloid tends to 
recur again and again. Injections of iodine, caustic potash, 
etc., usually prove futile, so that we are reduced to reliev- 
ing any severe pain, which on rare occasions may be present, 
by hypodermatic sedative injections and protecting the sur- 
face. If external resolvents are tried, care must be taken 
not to set up irritation. Internally, such medicines as iodide 
of potassium seem without effect. 

Lentigines are due to an excessive deposit of pigment 
in the lower layers of the rete, and take the form of yellow, 
brown, or black spots, and patches of various shades of 
color and of different sizes, but mostly of round or oval 
contour. Freckles or Ephelides are of two kinds, viz., "sum- 
mer freckles," which are excited by the sun in light-com- 
plexioned persons, and which disappear in winter, and 
*' cold freckles," which are not confined to fair-skinned 
people, are not excited by the sun, and do not disappear in 
winter. " Liver spots " occur usually as larger patches of 
pigmentation, and are popularly supposed to be caused by 
liver derangement. They are often not permanent, and 

10 



110 DESCEIPTION AND TREATMENT 

certainly sometimes seem due to functional disturbance of 
the chylopoietic system. 

Treativient. — The disappearance of these pigmentations 
is best hastened by the application of bichloride of mer- 
cury lotions (F. 56), of strengths suited to the particular 
skin. 

Lepra is an old term for Psoriasis, with especial refer- 
ence to the chronic ringed forms, and in this connection it 
has now very properly fallen into disuse. The term Lepra 
is now reserved for true leprosy. 

Lepra arabum, Elephantiasis grsecorum, True 
Leprosy, has a very extensive, and to some extent shifting 
geographical distribution, and is still found on every conti- 
nent and many islands, but wherever seen it presents the 
same features. In leprosy-infected countries the distribution 
of the disease is not equable and uniform, but it will be pre- 
valent in one district or village or town and perhaps absent 
in the immediate neighborhood, though apparently similar 
conditions exist. It does not appear to be limited by any 
condition of soil or climate, though it exists mostly in the 
tropics and in the plains ; yet it certainly flourishes notably 
by many seaboards and in the vicinity of water, although 
not universally so, and on this fact, mainly, has been 
founded the idea of its causation by indulgence in a putrid 
or wholly fish diet. In the Western Hemisphere it is 
found dotted about or in little centres ; among other places 
in New Brunswick, Cape de Breton Island, California, 
Oregon, and the States where it has been introduced 
chiefly by settlers, Chinese, Norwegian, and French. It is 
also met with in the Southern States, Mexico, the hotter 
parts of South America, the Sandwich Isles, and the West 
Indies. It attacks all races and ranks of life, and both 
sexes. No age is exempt, but it commonly appears about 



OF SKIN DISEASES. Ill 

puberty; infantile cases occur, though it is still a question 
whether leprosy is ever congenital. The exact cause of 
leprosy, and whether it can arise de novo, are for the 
present unravelled points, L e., whether it arises from 
restriction to, or excess of, any special food, or from 
climatic or malarial influences, or certain habits of life, or 
some special virus. Recent researches indeed prove that a 
peculiar bacterium {Baeillus leprce) is invariably present in 
the special lesion, and hence leprosy is possibly provoked 
and communicated by this bacterium. Whether, again, it 
is propagated by heredity or contagion, or both, are keenly 
debated points. If hereditary, it mostly descends in collat- 
eral lines, and tends to skip several generations ; and, as for 
contagion, the tendency of the best opinions is now towards 
the view that leprosy is contagious under certain conditions, 
such as the inoculation of the special discharges. Leprosy 
is one of the most fatal diseases, but' chiefly so on account 
of its complications, such as tuberculosis, albuminoid and 
Bright^s disease, ulceration of the bowels, exhaustion from 
discharges, etc. 

Leprosy is a chronic and essentially symmetrical disease, 
characterized by the development of a small-cell growth, 
like that of lupus and syphilis, in various tissues of the 
body, but especially affecting the skin, and in three chief 
forms — viz., first, an eruption of an erythematous type, 
which is more or less anaesthetic; secondly, a deposit 
around, causing compression and neuritis of, the cutaneous 
nerves and superficially placed nerve trunks, inducing 
widespread anaesthesia and severe trophic disturbances of 
a special character in the extremities ; and, thirdly, a more 
copious form of deposit, either diffused and infiltrated and 
appearing as tumefaction, especially about the face, or 
more localized, and taking the form of an eruption of 
nodules or the so-called "tubercles." This new growth 
may affect secondarily the mucous membranes leading 



112 DESCRIPTIOX AND TREATMENT 

from the mouth and nose, and, to a far slighter extent than 
the skin, the liver, spleen, and testes. Leprosy, after its 
inoculation or whatever the method of contraction, may be 
latent in the system for from two to fourteen years, which 
is explicable either on the theory that the hereditary taint 
requires special circumstances to develop it, or that the 
acquired poison, like that of hydrophobia, has a very long 
and variable incubation period. Premonitory symptoms 
of variable duration and ill-defined character have been 
generally described, many of them being referrible to the 
dyspeptic class. Pathognomonic drowsiness and profuse 
sweatings are characteristic of tuberculated leprosy, and 
the special primary eruption of non-tuberculated leprosy is 
said to be preceded by pathognomonic pains in the super- 
ficial nerves and loss of coordinated and grasping power. 

Two chief clinical types have by general consent been 
m.arked out — viz., the milder ancesfhetic or non-tvber ciliated 
form, and the more severe nodular or htbercidafed leprosy. 
Some affirm that these two types frequently run a distinct 
course throughout, whilst others hold that though this is 
true of the first variety, advanced cases of tuberculated 
leprosy are rarely seen uncomplicated by anesthesia (the so- 
called mixed cases). A third type has also been described 
(piacidar or spotted leprosy), but with doubtful expediency, 
as all cases of leprosy would appear to commence by an 
eruption. 

Anaesthetic, or Non-tuberculated, Leprosy has 

an insidious onset, and attention may be first attracted 
either by lancinating or other neuralgic pains in the ex- 
tremities, or by muscular incoordination in the hands, or 
by an erythematous eruption of a special character, or by 
anaesthesia of the extremities and contraction of the little 
finger. This eruption, w^hich is very constant, consists of 
erythematous spots or macules, one or two inches in diam- 



1 



OF SKIN DISEASES. 113 

eter, of an oval or circular shape, fairly well defined, not 
raised, nor at first ansesthetic, of a pale reddish bronze, 
light tawny, or cafe-au-lait tint in fair-skinned people, and 
of a bright yellow color in blacks; the skin of the macules 
is harsh, dry, non-perspiring from gradual atrophy of the 
sw^eat-glands, without furrows, and showing atrophy of the 
hairs ; situated mostly about the back, shoulders, nates, 
and the posterior aspect of the limbs. Patches may come 
and go without fever for one or two years, and after that 
time spread serpiginously and coalesce, covering large 
tracts of the body as w^ell as the limbs with discolorations, 
which last throughout the course of the disease. (See the 
diagnosis of Leucoderma.) Many of the spreading patches 
atrophy, or clear up in the centre, leaving an active raised 
edge. Characteristic anaesthesia develops in the patches, 
but is not confined to them. Ooincidently with these 
changes the neoplasm collects round the superficial nerves, 
beginning with the ulnar, median, radial, niusculo-spiral, 
posterior tibial, etc., and these may be felt to be thickened 
in certain situations. Their functions are interfered with 
by the compression and neuritis set up, and anaesthesia 
results over the areas corresponding to the peripheral 
terminations of the bundles of nerves implicated, and this 
anaesthesia is ever on the increase superficially and in depth 
as the disease progresses. The muscles of the hands atrophy, 
and the contraction of the little and ring fingers is one of 
the earliest symptoms. As the interossei, etc., waste, the 
hands assume gradually the characteristic bird-claw aspect. 
Injuries to the anaesthetic parts pass unnoticed by the 
patient. Important trophic troubles also ensue, which re- 
sult in interstitial absorption, necrosis, and caries of the 
phalanges, and extensive ulcerations. After some years, 
some muscular paralysis also supervenes — e. g., of the third 
nerves. The disease seems to progress for about ten years, 
and then to remain stationary or gradually die out. 

10^ 



114 DESCRIPTION AND TREATMENT 

Tuberculated Leprosy declares itself first by tlie 
outbreak on the jace commonly of one or more hyper- 
sesthetic, raised, thickened, erythematous, rounded patches, 
in size varying in diameter from one to several inches, and 
in color reddish or reddish-brown in the black, and a deep, 
dull red, livid, or mahogany in the fair-skinned. These 
patches begin as a mere blush, and gradually get raised and 
thickened by the new growth. They may come and go 
for some months, and their evolution is attended by febrile 
reaction. After a time they disappear altogether, and the 
course of the disease is henceforth marked by the repeated 
outbreak of " tubercles " or nodules of new grow^th, varying 
in size from a pea to a hen's ^g'g^ isolated or grouped, and 
more or less widely distributed. Their color varies, for 
in the fair-skinned they are pinkish at first and gradually 
get livid and deeply pigmented, and in the black they are 
pale colored at first. They last a variable time, and finally 
either become absorbed or atrophy, or they suppurate or 
ulcerate. The latter process may be very extensive, and 
the draining discharges form one of the worst complica- 
tions of leprosy. More or less fever attends the absorption 
and deposition of leprous material, and the related glands, 
especially the femoral, get much enlarged and obstruct the 
flow of lymph. Thus the profuse discharges, the febrile 
paroxysms, and the interference w-ith the lymph circula- 
tion, are the main factors in exhausting the patient. The 
chief sites for these "tubercles" are the head, face, and the 
ears, the extremities, mammae, and about the genitals. 
They are rarely seen on the back, the neck, and the palms 
and soles, and never on the hairy scalp. The lining mem- 
brane of the nose is frequently aflfected, also the throat, 
giving rise to the leper's peculiar croaking voice, and 
tubercles are often seen in the mouth and pharynx, and on 
the cornea and conjunctiva. The face is very early afiected, 
and becomes thickened, swollen in folds, and studded with 



OF SKIN DISEASES. 115 

tubercles. The lips become everted, the ears thicken and 
stand away from the head, the eyebrow hairs fall out, and 
a peculiarly ferocious or aged aspect is simulated. The 
new growth is also found in the liver, spleen, and testes, 
and in the latter situation interferes with the virile power. 
In pure tuberculated leprosy there is not the mutilation of 
joints seen in the anaesthetic variety. The average dura- 
tion of anaesthetic leprosy is about fifteen years; of tuber- 
culated, eight years. The new growth is possessed of special 
characteristics W'hich distinguish it from that of syphilis 
and lupus — i. e., the effused small round cells undergo 
peculiar degenerative changes, ending in the production 
of branched and irregularly shaped cells, and some special 
elements. 

Those acquainted with the affection can hardly confound 
it with any other disease. It is, hx)wever, frequently mis- 
taken, before amesthesia or trophic changes ensue, for 
syphilis. Leucoderma and ringworm in the dark-skinned 
are perhaps most likely to be confounded w^ith the macular 
forms. 

Tkeatmext. — Lepers greatly improve if they are re- 
moved from their usually filthy and poverty-stricken sur- 
roundings, and subjected to the influences of generous and 
fresh diet, personal cleanliness, and proper hygiene. There 
is no know^n remedy w^hich will " cure " or eradicate leprosy, 
but the indications are to support the general health in 
every way by tonics and healthy living, whilst the excretory 
organs are kept active, and at the same time to keep the 
skin free from leprous deposit by local stimulant or resolv- 
ent applications, such as carbolic oil. Of late years several 
oils — e. g., the cashew^, gurgun, and chaulmoogra oils, wath 
nourishing and alterative, laxative and diuretic, and stimu- 
lant properties, have come very largely into use, and the 
effects obtained from their use externally and internally 



116 DESCRIPTION AND TREATMENT 

(F. 35, 148, 149) are more satisfactory than from any 
other drug treatment. 

Leucoderma, or Vitiligo, or Leucopathia, is an 
acquired non-hereditary affection of the skin, occurring 
mostly in brunettes and in persons of a spare habit, char- 
acterized by the formation of rounded or oval, blanched, 
sharply circumscribed patches with a convex border, which 
constantly tend to enlarge and coalesce to form irregular 
areas, and which are surrounded with a concave border of 
increased pigmentation, fading off into the surrounding 
skin. As a fact, this hyper-pig men ted bordering varies 
much in degree in different cases, for though at times it is 
conspicuous, and indeed forms the leading feature, so that 
melasma is closely simulated, in other cases it is hardly 
recognizable. Still the affection seems to comprise essen- 
tially the double process, and not to be simply a pigment 
atrophy. Not infrequently it would appear to commence 
in hyper-pigmentation. Further, the surface of the patches 
is smooth, not scaly, and structurally unaltered, and its 
functions generally normal,^ and its sensibility intact, thus 
distinguishing the affection from any patches of morphoea 
or leprosy, which may superficially resemble it. The affec- 
tion is often very fairly symmetrical ; and when numerous 
the patches may coalesce until large tracts are involved. 
It occurs at any age, except perhaps in infancy ; in either 
sex, but oftener in females ; and both dark- and fair-skinned 
races are subject to it, though the former are more espe- 
cially prone. The sites mostly favored are the genitals, 
mons veneris, extremities, especially the backs of the hands 
and forearms, and the head and face. When hairy regions 
are involved, the hairs lose their pigment also. The causes 

1 Marked diminution of the sweating function has, however, 
been recorded as existing in some cases. 



OF SKIN DISEASES. 117 

of leiicoderma are still obscure, but there is a large con- 
sensus of opinion that the nervous system is at fault. Cer- 
tainly it is very closely allied to melanoderma. In some 
cases the health seems little affected, and no clue is forth- 
coming ; whilst in others there is marked debility, or there 
has been precedent exhausting disease. Again, it may 
closely follow an injury to the central nervous system or 
some nerve ; and it has been recorded many times in special 
association with disturbances of innervation, in ataxics, 
lunatics, etc. It appears, in some cases, to be directly 
traceable to acute emotions. It has been noticed in associ- 
ation with Addison's disease, and alopecia areata. Some 
persons, again, acquire it each summer on the backs of 
their hands. 

To prevent any error in the diagnosis, it is necessary 
to clearly make out the characteristic features of the pig- 
mentary disturbance as described above. Where the 
double process of the pigmentary disturbance is obscure, 
and its degree slight, it is easily confounded with melano- 
derma, and even with that associated with Addison's dis- 
ease, especially if the subject be tubercular. The diseased 
areas of skin in morphoea and scleroderma are sometimes 
much pigmented also. In the darker-skin races the re- 
semblance of leucoderma to the discolored skin of true 
leprosy is often remarkably close, and no doubt presents 
difficulties in many cases ; hence the unfortunate applica- 
tion of the term " white leprosy " to leucoderma. A careful 
search must be made in such cases for anaesthetic areas, or 
some other symptoms of nerve implication. Refer also to 
the " pigmentary syphilide." 

Treatment. — Where leucoderma is not traceable to any 
distinct nervous shock, the treatment is usually that for 
debility and ansemia, by quinine, ferruginous and nervine 
tonics, and cod-liver oil. The affection in many cases tends 
spontaneously to pass away in a few years. 



118 DESCRIPTION AND TREATMENT 

Lice. {See Plithiriasis.) 

Lichen tropicus. {See Miliaria.) (For Lichen urti- 
catus, see Urticaria papulosa.) 

Lichen is a term which has been in the past applied to 
a heterogenous collection of eruptions presenting in common 
the features of pimples or papules, and consequently it 
embraces many forms of papular eczema, of syphilides, 
miliaria, tinea circinata, etc. Now-a-days, the term lichen 
is reserved to denote one or two very definite diseases, 
which have this in common — that they are throughout 
their course papular, but are in other respects quite distinct. 

Lichen pilaris is a general term referrible to condi- 
tions of skin in which the hair-follicles are blocked up by 
a collection of epithelial scales and some sebaceous matter, 
causing the formation of little acuminate pale or reddish 
papules the size of millet-seeds, in the centre of which are 
to be detected twisted or stunted or broken-ofiP hairs. Such 
papules may inflame occasionally and become acneiform. 
There are several phases of disease here included : First, 
there is the plugging of the follicles, mostly about the 
limbs, so commonly seen in uncleanly people. Secondly, 
there is the rare affection to which the term is properly ap- 
plied, in which the greater part of the trunk and limbs is 
implicated, and rough and file-like in aspect and feel. The 
cause is very obscure. This condition was called Pityriasis 
pilaris by Devergie, who noticed it as a sequela of pityriasis 
rubra. Thirdly, we must distinguish the special plugging 
of the follicles sometimes seen in xeroderma {see Ichthyosis). 
Fourthly, we constantly meet with a plugging of the fol- 
licles with epithelial debris and sebum in children of a 
phthisical habit. It may occur in patches, or more or less 
generalized, and is closely related to Lichen scrofulosorum, 



OF SKIN DISEASES. 119 

etc. Not infrequently the little plugs stand out from the 
surface like bristles. 

Treatment. — This should be mechanical, and consist in 
repeated bathings and frictions of the parts with soaps of 
properly adjusted strength to soften and remove the plugs. 
{See also Ichthyosis.) Where the general health is obviously 
at fault, suitable internal measures may be adopted. 

Lichen planus is a somewhat rare, non-contagious, 
non-hereditary eruptive disease, characterized by the de- 
velopment of discrete papules of very peculiar characters 
as regards, amongst other points, their color, shape, struct- 
ure, tendency to aggregation, behavior, seat, chronicity, 
and accompanying melasmic staining. In color they are of 
various hues, from lilac to deep purple, and suggest to the 
mind purpuric extravasation, being of deepest tint on the 
legs. In shape they are flattened, but little raised, smooth, 
shiny, sharply defined, of angular outline, and they fre- 
quently, but by no means invariably, present a little um- 
bilication in their centre, and may appear to be developed 
round a hair- follicle. They vary in size from one to three 
lines in diameter, and may be covered with slight micaceous 
and adherent scales; but there is not the hyper-production 
of scales as in psoriasis, and not the bleeding points on their ^ 
removal. The papules are solid throughout, show no dis- 
position to take on an eczematous tendency, and are formed 
by hypertrophy of the rete. 

They are very chronic, they do not enlarge peripherally, 
as in psoriasis, but tend to become aggregated into irregular 
and not rounded patches and bands by the evolution of new 
papules amongst the old. In such areas the individuality 
of the central papules may be lost, and the true composi- 
tion of the patch only detected at the borders. The favorite 
seats of the eruption are the anterior aspect of the forearms, 
especially just above the wrist, the waist and flanks, the 



120 DESCRIPTION AND TREATMENT 

hips, and over the vastus internus about the knee. The 
distribution may be, however, much wider than this, though 
certain regions — e. g., the face and scalp — are excepted. It 
may begin anywhere, even on the penis, but most frequently 
on the extremities, and its rate of evolution varies very 
greatly. There is a marked tendency to symmetry, and, 
like psoriasis and secondary syphilides, to recurrence. 
General opinion seems to point out that women are more 
commonly affected, and, unlike psoriasis, it seldom or never 
occurs before puberty. The only remaining points of im- 
portance to mention, are the occasional implication of the 
nails, and palms, and soles, and the recurrence of white 
spots, patches, and streaks about the tongue, and buccal 
mucous membrane. Lastly, itching of the papules is a 
marked feature of Lichen planus, though its degree varies 
through a wide range. In Lichen planus only quite a few 
papules may present themselves; but in other rarer cases 
large tracts of skin are covered with infiltrated, sliglitly 
scaly patches, and such cases seem to lead by gradual steps 
to the more general and severe form of eruption described 
by Hebra as Lichen ruber, though some still hold that 
this close connection of these diseases has hardly been 
established. This very rare diflfuse form, w^hich often 
evolves acutely, consists of miliary papules, and as the 
successive crops develop they become aggregated into very 
extensive sheets, and the skin becomes infiltrated and 
slightly scaly. The irritation is often intolerable. The 
afiection is chronic, and the greater part of the body may 
be affected, including the nails. Marasmus sometimes sets 
in, and the case may terminate fatally. The aspect of the 
eruption is often more like that of a widespread miliaria 
rubra than Lichen planus. 

The cause of this eruption is still involved in obscurity, 
for whilst there appears to be but little derangement of the 
health in many persons, there is certainly in others marked 



OF SKIN DISEASES. 121 

laugoiir and feebleness, dyspepsia, and what raay be called 
nervous debility. Indeed, some insist that it occurs espe- 
cially in people of a neurotic temperament, and that it is 
associated especially with a weakening of the nervous in- 
fluence presiding over the vessels and nutrition. As to the 
diagnosis, experience teaches that Lichen planus is often 
confounded with psoriasis, but as it presents a manifestly 
different aspect and distribution to ordinary psoriasis, the 
eruption is put down as syphilitic psoriasis, by which in- 
correct terra is meant a late relapsing small papular syphilide. 
The latter is often glossy, very faintly scaly, of a dull-red 
color, chronic, and leaves melasmic stains; but it occurs 
mostly about the outside of the forearm, the papules do 
not tend to aggregation, and are not itching. A careful 
study of the description given above will generally obviate 
any difficulty. 

Treatment. — The treatment here recommended is not 
simply that of arsenic internally and tarry applications ex- 
ternally, though arsenic is held by some to possess a re- 
markable influence in this disease, but after correction of 
any marked dyspeptic disorder it is proper to raise the tone 
of the nervous system by quinine, cod-liver oil, the mineral 
acids, and full doses of perchloride of iron. Change of 
scene and air is often absolutely necessary. Externally, 
in the widespread cases, there is much hypersemia; alkaline 
and bran and starch baths are comforting, and some of the 
many soothing and sedative lotions prove more or less useful 
(F. 14, 15, 47, 83, 90). In the more indolent and less ex- 
tensive cases, tarry applications (F. 73-78) or other stimu- 
lants (16, 23, 24, 26, 31, 57, 60, 62) should be applied. 

Lichen SCrofuloSOrum is characterized by an erup- 
tion of miliary papules very similar in color to the normal 
skin, or pale yellow, or a dull red. The special features 
are, that although these papules may be more or less dis- 

11 



122 DESCRIPTION AND TREATMENT 

seminated about the trunk, and, perhaps, the upper part of 
the extremities, the eruption is generally limited to the 
trunk, and occurs in the form of small oval patches or 
crescents, and that there is usually a strumous family his- 
tory — e, g., of enlarged glands, spinal or hip disease, 
phthisis, mesenteric glandular disease, caries, etc. The 
papules often are crowned with a little scale, and some in- 
flame and form little acne pustules. There is usually but 
little itching. This is a very well marked and distinct 
phase of disease. It occurs in children especially, and is 
very rare indeed after puberty, so that it can hardly be con- 
founded with the crescentic and annular miliary syphilide 
(so-called Lichen syphiliticus) which may closely resemble 
it in appearance, but extends to the limbs commonly. 

Treatment. — If untreated. Lichen scrofulosorum is very 
chronic, but under anti-strumous dietetic and medicinal 
treatment, a cure is generally pretty easily effected. Cod- 
liver oil is, of course, the main remedy. Locally, mild 
stimulants may be applied (F. 31, 25, 52, 73-8). 

Lipomata. — Local hypertrophies of the subcutaneous 
fat, forming projecting growths, may occur in an analogous 
manner to hypertrophies of the fibrous tissue (fibromata), 
and such may be single or multiple. They vary in size 
from a bean upwards, and sometimes occur in great num- 
bers. They are rather softer than fibromata, painless, and 
lobulated. The skin over them is quite natural. Some- 
times they are associated w^ith a more diflfuse development 
of fat in certain regions, as fibromata are with derm atoly sis. 

Treatment. — This will be similar to that for fibromata. 

Lupus is a term applied at the present day to a definite 
disease of the skin (and some adjoining mucous membranes), 
clearly distinguished on the one hand from syphilis, and on 
the other from malignant growths. It is a non-contagious, 



OF SKIN DISEASES. 123 

chronic, and probably non-hereditary affection, character- 
ized by the formation of a new small-celled growth in the 
meshes of the cutis, closely resembling that of syphilis and 
leprosy, tending to spread peripherally, but not very deeply, 
by infection of neighboring cells, and finally to undergo 
an atrophic or destructive process ending in scarring 
or ulceration. Two groups of lupus are described: viz., 
Ltipus vulgaris, or true lupus, and Lupus erythematosus of 
German writers, which Kaposi considers not a true lupus, 
but an inflammatory disease belonging to a diflferent 
category. 

Lupus vulgaris presents itself under a multitude 
of aspects. Its slightest form, which is especially seen in 
the young, consists of small rounded or irregular patches 
of a deep-red color, of a somewhat dry, gelatinous aspect, 
and very slight elevation. It is like a very chronic 
erythema, and it gradually spreads at its periphery, whilst 
it atrophies in the centre of the patch. Slight scales may 
clothe its surface, and occasionally there is some slight 
exudation of leucocytes and fluid to form a thin crust. 
The seats of this variety are the forehead, cheek, and nose, 
occasionally the scalp and ears, and on the fingers, hands, 
and toes it closely resembles chilblains, but the patches are 
persistent and faintly scar. This erythematous variety has 
been described as Lupus erythematodes by English writers, 
and thereby much confusion has arisen with regard to thi« 
and the Lupus erythematosus of German writers to be 
described presently. The more pronounced phases of L. 
vulgaris commence with soft, semi-transparent, grayish, 
glistening nodules or papules, or so called "tubercles," 
which tend to become more or less aggregated and confluent 
and remind one strongly of the "gray granulations" of the 
lung. The surface is often glazed and wrinkled, and large 
scales may continue to separate (i. exfoliativus). It is 



12i DESCRIPTION AND TKEATMENT 

characteristic of lupus that, whilst the patch pursues its 
chronic spreading progress, by the evolution of fresh 
nodules at the periphery, the older central ones tend to 
atrophy without ulceration and to leave a scar, although 
nodules may recur in the cicatrices. Thus the patch may 
often be seen to assume a crescentic or serpiginous form 
(i. serpiginosus). Sometimes there is very marked papillary 
hypertrophy (i. hypertrophicus). Such coarse phases of 
lupus commonly arise about the face, less frequently on 
the limbs and the trunk, but may occur anywhere, as the 
genitals, and the patches are often widely separated, and 
do not tend to symmetry. But from any centre lupus may 
wander over extensive surfaces of the body, and spread to 
the eye structures and buccal and nasal mucous membranes. 
By the cicatrices left much inconvenience, and deformity 
if not inconvenience, arise — e. g., the eversion of the lids, 
and fusion of the lips and gums. Naturally there is a 
great tendency to ulceration of the new growth (L. exiil- 
cerans, formerly called L. exedens, as distinguished from 
L. non-exedens, the non-ulcerating forms), and some amount 
is very commonly seen, and of course increases the scarring. 
The ulceration is covered by a crust, beneath which the 
base is soft and fungous, and the ulceration advances at the 
hordiQv pari passu ^s\i\i the new growth. Still lupus does 
not, as a rule, tend to extend deeply, and generally in 
severe cases the most that results is the formation of exten- 
sive cicatrices, and atrophy and destruction of the carti- 
lages of the ears and nose. In rare cases, however, in 
some cachectic persons, phagedenic ulceration sets in, and 
is rapidly and profoundly destructive, especially about the 
face (Jv. vorax or tirebrant). 

Lupus erythematosus, of German writers, the L. 
sebaceus or seborrhagicus, or acneiform lupus of others, cer- 
tainly seems very closely allied to the L. erythematodes 



OF SKIN DISEASES. 125 

already described. The degree of vascular congestion 
present at first may vary widely, for a patch of erythema 
or a local seborrhoea may be simulated. The character- 
istic feature, however, is that dilated sebaceous follicles, 
plugged with little ropes of epithelial debris and inspissated 
sebum, stud the raised spreading border of the chronic 
erythematous patch, whilst the centre atrophies and leaves 
a slight scar, the whole forming thus a disk. This variety 
occurs on certain selected parts of the body — e.g,, the face, 
ears, scalp, hands, genitals, and rarely on the feet. A 
single patch may exist alone for a long time, or several 
develop in rapid succession, or only at wide intervals. As 
the patches spread they may join together, and over the 
nose and cheeks they coalesce to form the so-called " but- 
terfly-lupus." They tend to disappear in time, leaving a 
delicate cicatrix. Hebra and Kaposi describe two varieties 
— viz., L. erythematosus discoides, such as we have here de- 
scribed, and a i. erythematosus disseminatus et aggregatiis, 
characterized by the evolution of a great number of spots, 
and extending rather by the evolution of fresh ones than 
by spreading of the old, and leaving little atrophic pits. 
This eruption reminds one of psoriasis when superficially 
regarded. 

Lupus is most frequently seen in females, and, it is said, 
amongst the rural population. L. vulgaris develops com- 
monly from six to twenty-five years of age, and before or 
about puberty, whilst L. sebaceus occurs mostly in early 
adult life, but seldom later than thirty-five or forty. The 
latter phase is much less common than L. vulgaris. It is 
rare to find more than one member of a family aflTected. 
As to the cause of lupus, much conflict of opinion exists, 
for some hold that it is a purely local skin disease, whilst 
others think it is only the expression of a dyscrasia, viz., 
struma. Those who refuse to admit its strumous origin, 
admit, however, the notably frequent concurrence of evi- 

11* 



126 DESCRIPTION AND TREATMENT 

deuces of struma. Certainly, some patients appear to be^ 
in fair health, whilst very many are possessed of feeble con- 
stitution, and suffer from deranged menstrual functions, 
etc. The association of chilblains with lupus is frequently 
observed, and the identity of the sites attacked is often 
remarkable. Lastly, we may mention that lupus may be 
excited in predisposed subjects, by exposure to the sun, or 
to kitchen fires, or to cold, etc. The early stages of L. 
erythematosus frequently pass unrecognized, and are mis- 
taken for patches of chronic eczema erythematosum, or 
seborrhoea, or chilblains, but chronic erythematous patches 
about the face or hands, tending to slow spread at their 
periphery and scar in their centre, should always at once 
excite suspicion. The dilated follicles studding the part 
are also very characteristic. The more raised scaly patches 
have been mistaken for a chronic patch of psoriasis w^hich 
rarely exists, however, as a single patch about the face or 
fingers. The soft, semi-translucent nodules of lupus new 
growth, leaving scars, are very characteristic, but no doubt 
the serpiginous and ulcerated forms are occasionally liable 
to be confounded with tertiary syphilides, especially when 
no history of the latter disease is attainable. Even the 
most chronic superficial forms of rodent ulcer about the 
nose can hardly be mistaken, by paying attention to the 
characteristic hard-rolled edge enclosing the non-crusted 
scooped-cut ulcer of the latter. {See also Scrofuloderma.) 
In L. erythematosus there is a dilatation of the vessels, 
and an effusion of fluid and embryonic cells into the 
meshes of the cutis constituting the eruptive spots, and 
these changes are especially concentrated around the 
glands and follicles, leading to their hypertrophy, so much 
so that some consider it essentially and primarily a disease 
of the glands. As the process extends, the tissues of the 
older parts atrophy, and as the lupus cells are incapable of 
high development or further organization, they undergo 



OF SKIN DISEASES. 127 

fiitty degGneration and a scar consequently ensues. Kaposi 
and others think it,. at any rate at first, an inflammatory 
process, and different in nature to L. vulgaris, but others 
hold it only differs from the latter in that the cell infiltra- 
tion is less marked, more superficial and diffused, and 
shows less disposition to form " nests." The characteristic 
feature of L. vulgaris is the great amount of the chronic 
cell infiltration which tends to become concentrated in little 
*'foci," cell-collections, or so-called *Hubercles" which may 
contain a giant-cell. Indeed, Friedlander thinks these 
" nests " are identical with true miliary tubercles, but, 
Fagge says, there is not the same tendency to early casea- 
tion. Recently, the bacilli of tubercle have been recorded 
by several observers in the lupus nodules. The cell infil- 
tration extends along the vessels, and the nests coalesce 
into the projecting nodules or tubercles. Their ulceration 
history is as described above. 

Treatment. — In L. erythematosus, it is well to try to 
control the vascular congestion and infiltration of cells by 
local soothing measures (F. 20, 22, 83-86) or astringents, 
as glycerine of tannin, collodion, or perchloride of iron, 
and trust to internal medicaments to stop the process by 
elevating the general tone of the body, and counteracting 
any dyscrasia by arsenic, cod-liver oil, iodine, and tonics. 
If the patches are inflamed and crusted, they must be 
healed over by soothing unguents. It is generally held, 
however, that stimulating and resolvent applications are 
most efficacious, such as F. 31, 73-8, 68, 33, 44, 54, 
rubbed in thoroughly twice daily with a piece of flannel for 
weeks or months, or emplastrum hydrargyri (F. 88, 89) 
applied at night; others resort to painting on still stronger 
applications (F. 3, 10), repeated as often as the scabs pro- 
duced are got away and the surface healed. But this form 
of lupus is very intractable to these measures, and resort 
has been made of late years with some success to destruc- 



128 DESCEIPTION AKD TREATMENT 

tion of the growth by repeated stabbiugs with a lancet, or 
multiple linear scarification repeated in different directions 
at short intervals. For L. vulgaris, destructive measures 
are generally necessary, and every one almost has had his 
favorite caustic. Excision and cauterization have also 
been widely brought to bear. It must be remembered 
that, if incompletely destroyed, lupus will certainly return, 
by its powder of infecting other cells, so destructive meas- 
ures must be thoroughly carried out ; at the same time, the 
least possible scar is desirable. Hebra used largely F. 6, 
and F. 7 and 5 have been favorite remedies. Some like 
the late Mr. Startin's acid nitrate of mercury (F. 9) ; but 
decidedly the best remedy for the inexperienced to use is 
nitrate of silver in points, W'hich should be bored in all 
directions into the soft melting lupus grow^th. No harm 
can thus be done, as only the diseased tissues are destroyed. 
The treatment of this form of lupus has, how^ever, been 
revolutionized by the introduction of the sharp bone spoons, 
by which the soft lupus tissue can be scraped away thor- 
oughly. By this means you cannot do too much, as the 
healthy tissues resist the action of the spoon. Cod-liver 
oil and iodide of iron are undoubtedly of immense benefit 
internally in many cases of lupus, and the affection has 
been known to disappear under the influence of iodide of 
potassium. 

Lymphadenoma cutis is characterized by the de- 
velopment of tumors composed of adenoid tissue of various 
sizes and shapes in the substance of the skin. They are 
projecting, more or less rounded or oval, but generally 
flattened, firm and elastic, painless, more or less red or livid, 
and evidently stretching out the skin over them. They 
vary in size up to a small apple. They are usually discrete, 
and they may be few in number or very numerous. The 
trunk is especially implicated, though they may occur any- 



OF SKIN DISEASES. 129 

where. As they grow more or less rapidly, they generally 
break down in the centre, and unhealthy, ragged, fungoid 
ulcers are produced. Cachexia and emaciation sets in, 
and death ensues in a few years. This disease is closely 
associated with, and indeed may be complicated by, 
Hodgkin's disease and leucocythsemia. 

Medicinal Eruptions are those which are caused by 
the ingestion of drugs, and do not include the inflamma- 
tions of the skin excited by the external application of 
medicines. {See Dermatitis.) Many of these eruptions 
are very definite and constant, recur each time the drug is 
given, and disappear with the discontinuance of the medi- 
cine ; but some drugs excite at different times and in dif- 
ferent people a variety of eruptions. Neither age, sex, nor 
conditions of general health seem, as a rule, to exercise any 
influence, and although in some cases the eruption is due 
to the long-continued or large administration of the drug, 
in general it seems to depend on a special peculiarity or 
idiosyncrasy of the patient, and no exact dose can be fixed 
as exciting it, just as some articles of food always excite 
certain symptoms in some people. A knowledge of these 
eruptions is necessary, as they frequently simulate the 
rashes of the acute specific fevers, surgical and puerperal 
erythema, roseola, syphilis, etc. Their exact causation is 
still involved in obscurity — viz., whether due to reflex 
action from the gastro-intestinal tract, or influence on the 
nervous system, or direct action of the drug on the part, 
either by special selective action, or irritant influence ex- 
erted in its excretion. 

Arsenic need only be mentioned to say that it sometimes 
produces a brown pigmentation, and some erythematous 
blotches and urticaria, and that it has been credited by 
some with exciting herpes zoster. 



130 DESCRIPTION AND TREATMENT 

Belladonna (with which may be included stramonmm 
and hyoscyamus) seems to excite occasionally a vaso-motor 
paralysis and more or less widespread blush, or a scarla- 
tiniform or coarser erythematous eruption is described. 

Bromides, especially the bromide of potassium, excite 
many different phases of eruption, but all apparently spe- 
cially connected with inflammation of the sebaceous glands. 
It may appear after a slight dose or after the medicine has 
been long pressed, or shortly after discontinuance of the 
drug. The acneiform (papular and pustular) eruption is 
w^ell known, and is seen mostly about the ordinary acne 
sites, but occasionally it is widespread, and especially aflfects 
hairy parts. Sometimes these acne-like eruptions are con- 
fluent over erythematous patches and crustitial. Duhring 
describes a maculo-papular eruption with the sebaceous 
glands involved, accompanied by fever and constitutional 
symptoms, and simulating a syphilide. Furunculoid erup- 
tions also occur, and may ulcerate, as the other bromide 
eruptions tend to do, and be covered with rupioid crusts. 

Chloral sometimes excites a peculiar scarlatiniform or 
morbilliform rash without febrile reaction, as a rule, but 
associated with marked dyspnoea and great palpitation of 
the heart, etc., and supposed to be due to vaso-motor and 
pneumogastric paralysis. It is often determined and kept 
up by the administration of alcohol and meals. Its course 
is as follows : A diflused redness of the face with puffiness 
and conjunctivitis sets in, followed by well-defined and 
slightly elevated erythematous patches on the face and 
neck, extending and coalescing, and spreading to the shoul- 
ders, trunk, neighborhood of large joints, dorsum of hands 
and feet, etc. There is great irritation present, and the 
rash on the face is more crimson than elsewhere. It fades 
in a few days with occasional slight desquamation. 

Copaiba is well known to excite a papular erythematous 
eruption, much coarser than scarlatina, with a considerable 



OF SKIN DISEASES. 131 

urticarial element in it. It favors the hands, arms, knees, 
feet, and abdomen ; but is sometimes widespread. There 
is great irritation, a characteristic odor, and the rash fades 
without desquamation directly the drug is stopped. It 
must not be mistaken for syphilitic roseola. 

Ciibebs and Turpentine but rarely excite eruptions. 
Iodides, especially iodide of potassium, frequently excite 
eruptions, and may immediately follow small doses, and be 
due to idiosyncrasy and, it is thought, sometimes the non- 
elimination from diseased kidneys. As with the bromides, 
the eruptions vary very much. The acne-like eruption is 
very common, and occurs on the usual acne sites, but also 
about the limbs. It is but rarely confluent like the bromide 
acne. Peculiar bullae of various sizes have also been noted 
in a number of cases, usually on the head, neck, and upper 
extremities, and the contents vary much from simple scrum 
to a thick pultaceous mass. There is often an indurated 
base. Petechial purpuric spots, mostly about the legs, also 
occur, and urticaria, varying from the ordinary papules to 
large subcutaneous nodules, has been noted. Many re- 
gard most of the iodic eruptions as due to the irritating 
elimination of iodine by the glands, but others think they 
are due to a special action of the blood on the walls of the 
vessels. 

Opium and Morphia can produce a scarlatiniform rash, 
often very diffuse, and with puffiness of the f^ce, disap- 
pearing when the drug is discontinued, with desquamation 
sometimes very considerable. It is probably connected 
with the influence on the vaso-motor system and the diapho- 
retic action. 

Quinine and its allies pretty frequently occasion an in- 
tensely itching or stinging scarlatiniform or morbilliform 
eruption, often, however, largely associated with an urti- 
carial element, and generally attended with marked con- 
stitutional disturbance, commencing on the face and neck, 



132 DESCEIPTIOX AND TEEATMENT 

and spreading over the whole body. Usually much des- 
quamation ensues. 

Salicylic acid has been known to produce a diffuse or a 
patchy or papular erythematous eruption, sometimes asso- 
ciated with a sore throat. Urticaria and urticaria hsemor- 
rhagica have also been recorded. 

Many other drugs in rare instances excite eruptions, and 
only the chief have been here mentioned. 

Melanoderma, or Melanopathia, or Melasma, 

signifies a state of increased dark pigmentation of the skin. 
Before proceeding further, it is necessary to point out that 
an increased deposition of pigment in certain regions occurs 
during pregnancy, in some women at the menstrual per- 
iods, and about the foreheads and cheeks of females suffer- 
ing from dyspepsia and uterine derangements {chloasma 
uterinum et gravidarum) ; locally, after any irritant has 
excited a congestion of blood in a part — e. g,, after expos- 
ure to the sun about the hands and face (lentigines)] after 
prolonged exposure to the fire about the legs ; and after 
the application of blisters, and especially mustard. Again, 
it occasionally complicates morphcea and scleroderma in a 
marked degree, and is left after the disappearance of a 
host of eruptions, more especially syphilis and lichen planus, 
and is sometimes a very conspicuous feature in chronic 
phthiriasis and scabies. It now and then temporarily en- 
sues during the administration of arsenic, and rarely in a 
localized form about the neck. It is a secondary result of 
the syphilitic cachexia (pigmentary syphilide). True melano- 
derma, however, is a more or less widespread affection which 
cannot be relegated to any of the above-mentioned causes, 
and in what measure it is due to nervous influences (especi- 
ally involving the abdominal sympathetic) is still a debated 
point. However, certain cases would point strongly to such 
a causation — e. g., the well-known case of Kostan, who 



OF SKIN DISEASES. 133 

turned a very dark color iu a few days after condemnation 
to death; and Sarti's case of a man who, after a great 
fright, followed by severe illness, gradually got very dark. 
Extensive bronzing has been known to follow an injury to 
the back. It has also followed a severe attack of typhus. 
Other cases, again, of general bronzing at all ages, occur 
independently of any marked constitutional symptoms, and 
the cause is very obscure. There still remain two sets of 
cases, viz., the well-known melasma suprarenale^ occurring 
in connection with the destruction of the suprarenal cap- 
sules {Addison's disease), and an identical pigmentation, in 
which the capsules are healthy but the neighboring abdom- 
inal sympathetic is involved by a mass of diseased glands — 
the immediate cause, some think, of the bronzing in Addi- 
son's disease. Here there is a general deepening of color 
to brown or black pretty uniformly affecting the face, neck, 
backs of hands, the nipples, and genitals ; and Dr. Green- 
how has shown that Addison's disease very seldom occurs 
in persons past middle age, and that no partial discolora- 
tion of the skin can be relied on as diagnostic of Addison's 
disease in the absence of the characteristic constitutional 
symptoms. The presence of pigment patches in the mouth 
is not to be relied on as pathognomonic. 

Treatment. — Manifestly, the treatment of general 
bronzing must be as yet most unsatisfactory, and cannot 
be discussed in a short space. For the local treatment of 
pigment patches, see Lentigo. 

Miliaria is characterized by the formation of discrete, 
soft, bright- red, jorojecting, acuminate, excessively itchy or 
tingling papules, about the size of a pin's head or millet- 
seed {M, rubra). These papules may be capped by more 
or less fluid,^ either only detectable by a lens, or enough to 

^ It is uncertain how far this fluid is retained sweat or inflam- 
matory exudation. 

12 



134 DESCEIPTION AND TREATMENT 

make the eruption look like sudamina with congested bases. 
If this fluid gets opalescent, the term M. alba is applied, 
and these varieties may be seen commingled together with 
pure sudamina (Jf. crystallina), so that a multiform erup- 
tion results. The papules appear suddenly, last a few days, 
and a branny desquamation succeeds; occasionally, suc- 
cessive crops make the affection chronic. The eruption 
may be very closely set and associated with more or less 
general hypersemia. Miliaria is produced under similar 
conditions to sudamina, the only difference being that in 
the former there are active congestion and inflammation 
around the follicles, and in the latter not. It is seen, there- 
fore, not infrequently in the summer months, as a general 
eruption, and is to be diagnosed from papular and vesic- 
ular eczema, w^hich it often much resembles, and from such 
a disease as rotheln. In warm countries, the well-known 
intolerably itchy and pricking lichen tropicus, or prickly 
heat, is nothing more than severe miliaria, and agrees in its 
characters with the description given above. 

Treatment. — The most appropriate local applications 
are dusting powders (90), or a zinc and calamine lotion 
(83), and starch, or bran and alkaline baths (F. 1), are 
very comforting. Generally, the patient must adopt a cool 
regimen and light clothing, and avoid all habits inducing 
an excessive or sudden flow of sweat. Internally, saline 
laxatives and diuretics are useful, followed by a tonic. 

Milium, or Grutum (Strophulus albidus of Willan), 
is the name given to an unimportant eruption of little 
rounded white papules in the skin, the size of a pin's head, 
formed by the distention of the sebaceous glands and deep 
part of the follicles w^ith sebum. They therefore bear a 
close relation to comedo, but show no black point and no 
follicular orifice. They are seen about the face, especially 
the eyelids, of children and in adults, and occasionally 



OF SKIN DISEASES. 135 

may be met with more extensively over the body. They 
may reach in the latter to the size of a pea, or even more. 
Treatment. — Puncture and squeeze out the contents. 

MoUusCUm COntagiosum (Bateman) is charac- 
terized by the formation in the integument of softish or 
firm, rounded, projecting, movable, abruptly margined, 
discrete little growths, varying in size from a pin's head at 
their first appearance to a pea, or even larger. An um- 
bilication on the summit of each leads the way to a central 
cavity filled wdth milky or inspissated contents, w^hich can 
be squeezed out. The growths arise successively, and occur 
scattered sparsely or in groups, or crowded densely together, 
and their favorite site is the face, especially about the eye- 
lids and mouth, but they may be seen about the backs of 
the hands, or the genitals, or indeed anywhere except the 
pahns and soles. In adults they are in very rare instances 
seen as a general eruption. As each tumor grows very 
slow^ly, it acquires a semi-transparent look at the top, like 
a white currant or pearl button ; it gets pedunculated, and 
tends to spontaneous cure either by a wholesale shelling 
out or by necrosis. It is essentially a disease of ill-fed, 
dirty children, but is contracted sometimes by adults, or a 
like affection may arise idiopathically in the latter. It is 
held to be contagious, because the different members of a 
family may be successively attacked, or several boys in a 
school, or many children in a court, and because the 
growths arise on the neck or breast of the nurse of an 
affected child, or it spreads in a hospital ward. No defi- 
nite parasitic contagium has yet been made out. The 
exact nature of the growths, too, is a matter of controversy, 
for whilst their sebaceous origin (hyperplasic gland with 
degenerated contents) has long been unquestioned in Eng- 
land, principally by reason of the compound racemose 
gland-like structure, of late many competent observers, 



136 DESCRIPTION AND TREATMENT 

from a study of the earliest appearances, conclude that 
they originate in the rete, and that the outgrowths become 
folded gradually into this gland-like structure. In chil- 
dren the diagnosis is only from warts ; in adults, from warts 
especially about the genitals, and from commencing fibro- 
mata (formerly called molliiscum fibrosum). 

Treatment. — The subjects of the eruption are ahvays 
those much benefited by tonics and cod-liver oil. Locally, 
the growths must be enucleated by squeezing between the 
nails, or be destroyed by a little acid or caustic, and pend- 
ulous ones should be ligatured. 

Morphoea^ of English writers, Sclereme en pla- 
cards, or Sclerodermie en plaques, of the French. 
— Addison's Keloid, as distinguished from the true or 
Alibert's Keloid, is a somewhat rare afiection which, when 
once fully understood, can hardly be confounded with any 
other, but which presents much diversity of aspect, in con- 
sequence chiefly of the varying predominance of either 
hypertrophic or atrophic processes in the cutis, disturb- 
ances of pigmentation and vascular supply, and lastly dis- 
tribution. A patch of morphoea usually commences as a 
delicate pigmented or rosy circumscribed blush or tache, 
whose centre gradually becomes depressed and more defined, 
incapable of being pinched up by the fingers, and gets 
paler and w^hiter, whilst the border is still surrounded with 
the purple or lilac halo, fading aw^ay gradually into the 
healthy skin. The central part gets solid, smooth, and 
polished, and the degree of whiteness increases from the 
hyperplasia and condensation of the connective tissue, and 
obliteration of the vessels, until it suggests a piece of ala- 

1 This disease is not to be confounded with any of the eruptions 
occurring as a part of Leprosy, and described formerly or now 
known (Spanish South America) as Morphoea. 



OF SKIN DISEASES. 137 

baster or bacon fat having been let into the skin (itf. tube- 
rosa vel lardacea). Sometimes the epidermis gets like 
the bladder over a jam-pot, or separates. Simultaneously 
there ensue from the same causes more or less anaesthesia, 
blanching, or absence of the hairs, cessation of the func- 
tions of the sweat and sebaceous glands, and disturbance 
of the vascular supply, so that venules and dilated capil- 
laries may be seen coursing irregularly over a patch, or 
more particularly showing as a violet halo round the edge. 
Occasionally the hyperplasia is sufficient to cause the 
actual projection of the surface into lumps or nodules, to 
which the term M. tuber osa would seem more applicable, 
and the hyperplastic process is finally succeeded by an 
atrophic one, causing a depression below the surrounding 
surface {M. atrophica). 

This atrophy, however, may set in from the first, without 
the intervention of any marked hypertrophy, and we ob- 
serve, then, only either a shiny, smooth, tense, shrunken, 
circumscribed area of skin, which seems closely bound 
down to the underlying parts, and if about a joint, seriously 
impeding its movements, or over the supra-orbital notch a 
depressed furrow. There may be considerable pigment 
disturbance in any of these phases, but mostly in the 
atrophic form, and then either the whole surface of the 
patch, or its periphery only, may be of a bistre, brown, or 
black color. The patches of morphoea tend to the rounded 
form, and vary commonly from the size of a half-crown to 
the palm of the hand, but they may be of irregular shape, 
or in the form of bands, and may exist as tiny spots (see 
also Atrophia cutis), or cover extensive areas by conflu- 
ence (see Scleroderma). In number there may be only a 
single patch, at any rate for some time, or only two or 
three, or a great many, and though they do coalesce, it is 
remarkable how they tend to remain isolated. The favorite 
sites are the base of the neck and upper part of thorax, the 

12* 



138 DESCETPTION AND TREATMENT 

submammary region, the abdomen, the forehead, and then 
the extremities, especially the proximal parts, but no part 
can claim exemption. Its distribution also bears a relation 
which is very marked, in some cases, to that of the cutane- 
ous nerves, as over the first division of the fifth ; and again, 
it may be markedly unilateral, and only show apparent 
symmetry when the patches are bilateral and multiple. 
Mr. Hutchinson, indeed, goes so far as to say that the laws 
of distribution of herpes zoster apply here also. The onset 
and course of the affection are essentially chronic and insidi- 
ous, one patch succeeding another after some interval, and 
attention may only be drawn by some local tingling, or 
itching, or numb feeling. Occasionally, the progress is 
more acute. The patches may remain stationary a long 
time, or come and go for many years (over thirty certainly), 
or the whole thing may clear up spontaneously. The prog- 
nosis is fairly favorable. It occurs mostly in females of 
weakly constitution and nervous temperament, and is very 
frequently associated with debility arising from pregnancy, 
lactation, and uterine derangement. It is met with mostly 
in the young and in early middle-life, and it may be con- 
sidered as due to a nutritive debility especially affecting 
the nerves, and resulting in a concurrence of both hyper- 
production of lowly organized connective tissue and atrophy, 
interfering secondarily with various skin functions. 

The diagnosis is from leucoderma, in which no structural 
changes occur ; from the early eruptive phase of ancesthetic 
leprosy, in which there is a small-celled growth of a differ- 
ent nature, without the marked hyperplasia of connective 
tissue ; and from Alojoecia areata about the scalp, which is 
a simple atrophic process. Whether ifr is identical in 
np.ture with scleroderma — in fact, a circumscribed sclero- 
derma — is still siib judice; but the coalescent and more 
diffuse forms are at any rate closely similar in aspect. 



OF SKIN DISEASES. 139 

Treatment. — This should include good air, exercise, 
Dutritious food, cod-liver oil, mineral acids, phosphoric 
acid, strychnine, iron and quinine, and arsenic. 

Locally, mild stimulant liniments and other applications 
such as lin. camph. co., tinct. and lin. iodi, mild mercurials, 
etc., may be used, short of setting up inflammation, and 
the continuous electric current is very useful. 

Nail Affections. — 1. The nails, like the hair, are fre- 
quently implicated in any general malnutrition associated 
with a departure from the standard of health of the body — 
e, g., we see from this cause opaque specks and patches in 
the nails, or a transverse groove from almost complete ces- 
sation of growth in severe illness, or a thinning, so that 
they may easily bend or break, or " clubbing " in any 
chronic interference (heart and lung disease) with the pul- 
mons^ry circulation. 

2. The nails may also become involved in more or less 
generalized affections of the skin — e. g., they may be shed 
in pemphigus, and in the general desquamation after scar- 
latina ; pustules (variola) or papules may form under the 
nail, as elsewhere ; or they may get thickened, opaque, and 
rough in lichen planus et ruber, and in pityriasis rubra 
and psoriasis {see helow). They may be implicated in ich- 
thyosis and leprosy, and the matrix may participate in the 
inflammation in eczema {see p. 69) and chronic severe 
scabies. Lastly, in secondary syphilis, occasionally, the 
nails may become opaque, rough, and thinned, without 
affection of the matrix (Hutchinson), and in later syphilis, 
and probably in scrofula, the nail-bed of one or more nails 
— for it is generally multiple — may become the seat of 
offensive suppurative inflammation. Chloral, too, in rare 
cases, produces an ulceration round the nail. 

3. The nails share also in more localized disturbances of 



140 DESCRIPTION AND TREATMENT 

nutrition, as in injury or paralysis of a limb or nerve, or 
embolism of a vessel (shedding, hypertrophy, etc.). 

4. Disease may be localized in the nails, as by the attack 
of a fungus (^see Onychomycosis); or by the action of 
arsenic (stained yellow, greenish, or purple in centre) ; or 
dyes, and then the surrounding matrix or folds may be in- 
flamed and suppurate. Sometimes from neglect or boot- 
pressure, one or more nails, especially on the feet of old 
people, may grow enormously long, and get discolored and 
variously twisted in the growth ( Onychogryphosis), or the 
great toe-nail, particularly, may, in its growth, get pressed 
into the flesh, and set up inflammation (^Ingrowing toe-nail)y 
or an inflammation may arise from injury by a blow or 
splinter. 

To two conditions it is necessary to refer more particu- 
larly. When eczema of one or more fingers, or other 
inflammation, spreads to or attacks the folds of the nail 
(^Paronychia), or the matrix ( Onychitis'), the proper growlh 
of the nail is interfered with, and the nail gets rough, 
uneven, pilted and furrowed, discolored, and sometimes 
distorted with imperfectly developed nail substance; or 
the formation of the nail ceases altogether, and as the nail 
travels onward, a curved ragged proximal border is left, a 
condition seen sometimes as the result of atrophy from 
general causes. In both these conditions the nails may be 
shed. So-called psoriasis of the nails is a term vaguely 
applied to a variety of hypertrophic conditions, either 
occurring in connection with general psoriasis or idiopathi- 
cally. The nail gets glazed, discolored, and pitted ; under- 
goes loss of cohesion and disintegration from the free edge 
and sides, and becomes thickened, brittle, and raised at the 
free end from its bed by a mass of epithelium. When 
accompanied by a general eruption, usually one or tw^o 
fingers are affected, but sometimes nearly all the fingers 



OF SKIN DISEASES. 141 

and toes of both sides are involved without any clue to its 
causation. 

Treatment. — Any constitutional condition — e, g., 
syphilis and scrofula — underlying the affection of the nails, 
must be combated by the usual remedies. Any inflamma- 
tory condition, such as eczema, must be subdued by the 
applications in use elsewhere, and the new nail Avill then be 
properly formed. If the nail-bed be suppurating, the nail 
must be removed, and the suppurating surface destroyed by 
antiseptic lotions or iodoform. An ingrowing toe-nail 
should be properly pared away and trained to grow 
properly, whilst the flesh is protected. Psoriasis of the 
nails, if associated with general psoriasis, is w^ell influenced 
by arsenic, but the idiopathic condition is very intractable. 
Here the nails must be softened by soaking in hot water, 
and pared to the matrix, into which tarry and mercurial 
salves should be rubbed (F. 75, 53-55). 

NaBVUS is a term applied to certain localized hypertro- 
phic conditions of the skin and subcutaneous connective 
tissue, either congenital or acquired soon after birth, and 
involving either all the skin structures, or specially the 
bloodvessels, the papillse, the hair, or the pigment, or several 
of these combined. They are popularly attributed to impres- 
sions or shocks received by the mother, or to her longings 
whilst enceinte. Blood vascular nsevi {Angiomata) consist 
of dilated, distorted vessels, which are in great excess in the 
part and freely communicate, and the varied appearances 
and symptoms they present depend upon the depth to which 
they extend, or at which they are situated ; upon their size, 
which varies from a mere spot {Nceviis araneus) to the area 
of the palm of the hand, or more ; upon the extent to 
which they are raised above the surface, and are complicated 
by hypertrophy of the hairs or papillse, or admixture of 
connective tissue or fat ; and, lastly, upon the proportion 



142 DESCRIPTION AND TREATMENT 

of capillaries, arteries, or veins composing them, and the 
activity of the circulation through them. The common 
delicate so-called " claret or port wine stains " are formed of 
capillaries, and their distribution in relation to nerves 
is sometimes very marked, as also is the case with other 
kinds of n^evi. A great number of names have been 
applied to nsevi, according as they are erectile, or pulsating, 
or cavernous, or subcutaneous and encysted, or lobulated, 
or mixed with fat. Nsevi may be multiple, and may not 
grow at all, or after some growth remain stationary ; many 
also tend to degenerate and disappear spontaneously. The 
various patches of excessive pigment {N.pigmentosus, toad 
marks), of excessive hairy growth (N.pilosus, mouse marks), 
and of hypertrophied papilla3, or warty growths {N, verru- 
cosus) are included under the term moles or spili. These 
several conditions usually coexist. They are generally 
acquired soon after birth, and may be single or multiple. 
Lymphatic nsevi are much rarer. 

Treatment. — This must manifestly depend, in the case 
of vascular nsevi, upon the size, the site, the depth at which 
the nsevus is situated, and its formation. Compression, 
scarification, tattooing, vaccination, acupuncture with 
needles, hot or medicinally coated, cauterization by acids, 
acid nitrate of mercury, ethylate of sodium, and the gal- 
vanic cautery, the incitement of inflammation by the 
application of croton oil or tartar emetic, the use of setons, 
the injection of perchloride of iron, iodine, etc., and 
electrolysis are all means of cure adopted according to cir- 
cumstances in the slighter forms, whilst, in addition, in 
more formidable cases, we can further excise, or use one of 
the several methods of ligature. Scars must necessarily 
result from their removal, where the latter is necessary or 
desirable, as with the various forms of moles, though it may 
be much diminished by the transplanation of skin from 
other parts. 



OF SKIN DISEASES. 143 

Onychomycosis includes two diseases of the nails, 
dependent on the growth respectively of the favus and of 
the ringworm fungus. Only one or a few of the nails are 
usually affected, and these the finger-nails, though a toe-nail 
has been known to be also involved. If nails on both hands 
are involved, any symmetry is exceptional and accidental. 
The fungus either reaches the nails from a neighboring 
ringworm or favus of the hands, or is inoculated from 
patches elsewhere, as on the head. The affection is most 
commonly seen in those attendant on fungus cases. The 
affected nails become opaque, discolored, and softened, and 
the layers disintegrated, so as often to form a gryphotic 
mass. These changes commence and spread from any 
margin, and, as a rule, the surface of the nail is not notably 
roughened. The fungus will be found between the layers 
of cells, after a good soaking in liquor potassse, consisting 
mostly of large beaded mycelial tubes. 

Treatment. — As the nail is softer than natural, it is 
more easily scraped and cut away. In addition, continuous 
soaking of the nail by means of rag soaked in parasiticide 
lotions is effective, and the hyposulphite of soda (3j-ij to §j 
of water) is a good and cleanly application. If from any 
reason this course is impracticable, rub in thoroughly 
unguents containing parasiticides, such as thymol (F. 80) 
and salicylic acid (F. 64). 

Pediculi. {See Phthiriasis.) 

Pemphigus is an uncommon, non-contagious disease, 
mostly of very definite character, which is characterized by 
the formation of bullse, arising in typical cases abruptly 
from the skin, and not surrounded by any areola. Whether 
there is a precedent erythematous spot depends on the 
rapidity of the fluid exudation, but as a rule it is very 
rapid. In size the bullse vary greatly, and the variation 



144 DESCRIPTION AND TREATMENT 

may be seen in any one case, from a pea to a nut, but they 
may be much larger, and it is certain also that they may 
be the size of herpes vesicles, and in rare cases pretty 
uniformly so. It is necessary for diagnostic purposes to 
appreciate this fact. There may be one or two or a great 
number present. In form they are mostly rounded or oval, 
dome-shaped and tense, and they are filled at first by yel- 
lowish serum, which later becomes cloudy, puriform, or 
rarely bloody. Like herpes, and unlike eczema vesicles, 
they do not spontaneously rupture as a rule, but after a 
few days gradually collapse. They may occur singly or be 
irregularly disseminated, or be grouped corymbosely or in 
crescents. In rare cases the disease runs an acute course,^ 
but it is a very characteristic feature of most cases to be 
continued over a long period, perhaps years, by the succes- 
sive evolution of bullae, singly or in crops. They do not, 
as a rule, give rise to much distress, beyond some itching, 
or perhaps burning, but occasionally the sensations are 
very marked and intense. Neither are the general symp- 
toms very noticeable often, though the evolution may be 
attended or preceded by some febrile disturbance, and not 
infrequently the subjects are manifestly debilitated, anaemic, 
and even cachectic. In the latter cases the bullae may 
coalesce, and their bases be the seat of ulceration and 
crusting discharge, and some cases gradually progress to a 
fatal termination. From this statement it will be seen that 
the exact causes are obscure, and beyond noting its fre- 
quent association with nervous debility, gestation, etc., it is 
somewhat vaguely referred to a neurotic causation. No 
part of the body is really exempt, although the limbs are 
certainly mostly attacked ; bullae may be seen even on the 
buccal and vaginal mucous membranes. In the diagnosis 

^ Many cases of so-called acute pemphigus belong, no doubt, to 
the vesicating erythemata. 



OF SKIN DISEASES. 145 

of peniphigns but little difficulty can occur, although it 
must be remembered that bullse may form in the vesicat- 
ing forms of erythema multiforme and chilblains, in scabies 
(epidemic pemphigus of workhouses), in some drug erup- 
tions (e. g., iodide of potassium), about the hands in dysi- 
drosis, and in syphilis, though in the latter disease the 
ecthymatous pustule is far more often simulated, except on 
the palms and soles of newly born children. 

There is a very rare variety of pemphigus called P. 
foliaceus, which, beginning at one spot, commonly extends 
all over the body, and is characterized by the abortive 
character of the bullae, wdiich never rise into distinct tense 
blebs, but by their great number and coalescence give rise 
to flaky incrustations, and the disease usually terminates 
fatally after a variable time. It has to be distinguished 
from the very rare universal forms of eczema and the still 
rarer psoriasis, and especially from pityriasis rubra. 

There are some other rare forms of abnormal vesicular 
or bullous disease which, for the present, may be considered 
^under pemphigus — viz., (1) cases in which the bullse are 
uniformly small throughout (^Pemphigus d petites bulles), 
and are sometimes preceded or succeeded by prurigo-like 
itching papules (F, priiriginosus) ; (2) Herpes gestationis, in 
which, w^ith recurring pregnancies, an intensely itchy mixed 
eruption of papules, vesicles, and bullae occurs pretty ex- 
tensively over the body ; (3) Herpes impetiginiformis 
(Hebra), mostly a fatal affection, attended wdth great con- 
stitutional disturbance, in which vesicles grouped on in- 
flamed bases, commencing about the genitalia, and, spread- 
ing widely, terminate in impetiginous crusts ; and (4) 
Dermatitis circumscripta herpetiformis (Keumann), a disease 
pursuing a chronic course with great irritation, and impli- 
cating large surfaces of the body, in which papules appear, 
and spread peripherally to coalesce with others, whilst 
vesicles later surmount the centre and the spreading border. 

13 



146 DESCRIPTION AND TREATMENT 

Treatment. — In many cases arsenic (F. 139 et seq.) 
unquestionably acts like a charm in subduing the evolution 
of bullae, and its administration should be continued for 
some time after the bullse cease to appear. In all cases a 
general strengthening treatment should be pursued, by 
iron preparations, bark, cod-liver oil, etc., and in cachectic 
cases good food and hygiene are very necessary. Locally, 
the buUse may be punctured, and a soothing dusting powder 
be applied (F. 91). In some extensive cases antiseptic 
oily applications (e. g., carbolic oil and F. 49) are necessary 
to prevent drying and cracking of the surface and irrita- 
tion, and can be applied after a bath. In very bad cases, 
more or less continuous or prolonged bathing in warm 
water affords great comfort. 

Phthiriasis, Pediculosis, and Lousiness are terms 
applied to the disordered state of the skin produced by 
the attacks of pediculi or lice, and it is not to be con- 
founded with Prurigo, a disease sui generis, and wholly 
unconnected with the presence of pediculi. Three species 
of pediculi attack man — viz., the Pediculus capitis, the 
head ; the P. pubis, or crab-louse, mostly the pubic region ; 
and the P. corporis vel vestimenti, the body. The intrusion 
of the proboscis of the louse into the follicles for the pur- 
pose of sucking up juices and blood occasions a localized 
inflammatory papule or urticarial wheal, and in children 
often a pustule, and secondary scratching to relieve the 
irritation, which, in its turn, causes further inflammation 
mostly simulating eczema, and varying in degree according 
to the state of nutrition and constitutional tendencies of 
the subject, just as with scabies. 

Phthiriasis capitis, or Pediculosis capillitii, is 
found on the heads, chiefly of uncleanly and badly nour- 
ished children, but also not uncommonly in the long hair 



OF SKIN DISEASES. 147 

of adult females who intimately associate with such chil- 
dren. The sucking and movements of the lice excite a 
papular, scaly, or, in children, a pustular eruption particu- 
larly about the occiput, frequently spoken of as Impetigo 
or Porrigo capitis. The pustules may dry into isolated 
thick crusts, or coalesce to form weeping surfaces, and the 
discharge mats together the hair into an offensive mass, 
w^hilst the related glands simultaneously inflame. From 
the scalp the pus is further inoculated about the face, neck, 
and hands. {See Impetigo contagiosa.) The lice lay about 
the bases of the hairs little whitish eggs or "nits," which 
are plainly to be seen and are very characteristic, and these 
"nits" hatch in about nine days. In children this disease 
should be distinguished from eczema of the scalp and face 
by its site at the poll and the presence of nits, though it 
must be remembered the two diseases may complicate one 
another. In adults it can only be confounded with the 
matted hair and inflamed scalp from dirt. 

In Phthiriasis pubis, the crab-louse especially affects 
the hairy regions of the pubis and genital regions of adults, 
but may be found after a time on any hairy part of the 
body, as the axillae and limbs, and, in extreme cases, even 
in the w^hiskers and eyebrows. A scrutiny readily shows 
the square flat louse as a dark object clinging to the bases 
of the hairs with its powerful claws. It causes much itch- 
ing, but rarely more than a slight dermatitis. The eggs 
are attached to the bases of the hairs. 

In Phthiriasis vestimenti the lice leave their lair 
to run about over the body for food, and w^hen the patient 
is stripped they decamp, and may be found by careful 
search, with their eggs in the folds of the clothing. These 
pediculi excite, by their sucking, a little hemorrhage, which 
crusts over the mouth of the follicles, and remains after 



148 DESCEIPTION AND TREATMENT 

the inflammatory papules, which also form, have subsided. 
In addition, scratching forms excoriations, urticarial wheals, 
and a dermatitis closely simulating eczema, of varying de- 
grees of intensity in different subjects. The lice may 
attack any region, but especially favor the shoulders. 
They are found at all ages and in both sexes, but are par- 
ticularly partial to ill-nourished and debauched elderly 
people (hence the old synonym Prurigo senilis), in whose 
skins chronic phthiriasis sometimes occasions deep pigmen- 
tation. Phthiriasis corporis must be distinguished from 
true prurigo {see that disease) ; from papular eczema, which 
does not specially favor the shoulders and neck and waist; 
and from chronic scabies, which selects particularly the 
stomach and thighs and penis of adults, and the buttocks 
and feet and hands of children. 

Tkeatmext. — In j^hthiriasis we have to kill the lice, re- 
move the nits, and heal the inflammation. Therefore, where 
possible, in P. capitis the hair with the nits attached should 
be completely removed close to the scalp, especially if the 
latter is very inflamed, and the inflammation then subdued 
by a mildly astringent salve (also anti-parasitic), such as 
F. 52, or by oleate of zinc ointment. If the hair cannot 
be removed, the scalp may be soaked repeatedly for twenty- 
four or forty-eight hours with common kerosene oil, which 
kills the lice and shrivels up the nits ; or daily with spirit 
or acetic acid or bichloride of mercury lotion ; the hair is 
afterwards to be thoroughly washed with a parasiticide 
soap, and a fine-tooth comb used persistently. Carbolic oil 
is a good remedy, and also F. 62 and 110 {see F. 103-110). 
In P. jmbis, white precipitate powder dusted freely on, or 
any mild mercurial salve smeared on, or, if there is no raw 
surface, bichloride of mercury lotion (gr. viij to aq. 3ss) 
dabbed on, will speedily kill the lice. Treatment should 
be kept up for a fortnight in case any eggs hatch. In P. 
vestimenti the clothes should be thoroughly baked in an 



OF SKIK DISEASES. 149 

oven, or, better still, compressed steam disinfecting oven 
(200^ F.). The patient's skin then really requires only a 
thorough washing with disinfectant soap, or healing with a 
bland salve. If means are not at hand to bake the clothes, 
the treatment is far less satisfactory, and the skin must be 
coated thickly (so as to soil the clothes) with carbolic oil 
or ung. staphisagrise, or F. 103-110, and a thorough change 
of clothes effected. Probably, however, lice can live in 
clothes without nourishment for some days. The decoctions 
of sabadilla and cocculus indicus are cleanly applications. 
The general health must be looked after in all cases. 

Pityriasis is a term which has been loosely applied to 
a number of conditions in which there is an excessive shed- 
ding of fine bran-like scales from the skin. There may be 
also more or less attendant hypersemia. Such a condition 
occurs in xeroderma (so-called '^ congenital pityriasis "), in 
simple dermatitis, caused by heat, cold winds, and irritants, 
in the erythematous and declining stages of eczema, and in 
other affections attended by an excessive determination of 
blood to the surface ; also as a consequence of the growth 
of the microsporon furfur (tinea vel pityriasis versicolor), 
and again in the mildest forms of seborrhcea (" dandruff"). 
Branny desquamation also follows some exanthematous 
rashes and sweat eruptions. The term Pityriasis is now 
retained principally in connection with, first, an uncommon 
affection, at present unrecognized in England, called P. 
maculata et circinata; secondly, another rare condition fol- 
lowing pityriasis rubra, and consisting in a plugging of the 
follicles by epidermal products, and known as P. pilaris ; 
and, thirdly, a well-marked and severe disease termed P. 
rubra, which it is necessary to be acquainted with. 

Pityriasis rubra, or general exfoliative derma- 
titis, commences as a reddened scaly patch on some part 



150 DESCRIPTION AND TREATMENT 

of the body, and with more or less rapidity the whole 
surface becomes involved, and fully developed cases are 
characterized by a strikingly deep-red color of the skin, 
which is covered by large imbricated, loosely adherent 
scales or flakes of epidermis, which subsequently exfoliate 
continuously in enormous quantities. The disease may run 
an acute course, tending to a fatal issue, with prostration 
and emaciation, and subsequent diarrhoea, albuminuria, and 
pulmonary oedema, or be extremely chronic. Relapses are 
frequent, but some cases quite recover. To the simpl-e 
hypersemia present at first, may be added later, in chronic 
cases, more or less brawny infiltration stiffening the face 
and joints. Slight febrile action of a remittent type is 
common, the nails may be affected and shed, some fissures 
and slight oozing of serum may be present in places, and, 
lastly, some itching and burning sensations. As the 
universal hyperiem.ia and redness, with more or less shed- 
ding of flakes of skin, may be the leading features in 
chronic squamous eczema, in universal psoriasis, in lichen 
ruber, and in pemphigus foliaceus, the diagnosis is con- 
fessedly sometimes surrounded with difficulties. 

Treatment. — Locally, the application of bland lubricat- 
ing preparations are best, such as lin. calcis, glycerine of 
starch, but the surface must be kept very clean. Internally, 
arsenic is in high repute for many cases, and generally the 
system must be persistently toned up by tonics, especially 
of the nervine class, whilst the kidneys are kept active. 

PorrigO is a term now almost obsolete, but was formerly 
applied OVillan) to a motley group of eruptions, mostly 
pustular and contagious, such as different aspects of favus, 
but also including alopecia areata, and ringw^orm of the 
scalp (Plumbe). Later, Startin limited the application of 
the term to a contagious eruption of large flat pustules, 
terminating in thick crusts, and without a surrounding in- 



OF SKIN DISEASES. 151 

flamnuitory base, occurring anywhere on the body^ but 
mostly on the scalp and face. But this even included 
probably several distinct affections. {See also under Im- 
petigo.) 

Prickly heat, or Lichen tropicus. {See Miliaria.) 

Prurigo is characterized by the development of isolated 
papules, the size of a hemp-seed, of the same color as the 
healthy skin, or slightly pinker, and widely scattered over 
the surface, though leaving certain surfaces free. These 
papules, which are intensely itchy, are described as being 
subepidermic at first, and more readily appreciable to the 
touch than the sight, but later projecting distinctly, and 
acquiring a redder color from the means adopted to relieve 
the itching. The scratching abrades the top of many 
papules, which become capped with a tiny blood clot, or 
serum or pus exudes and crusts to simulate eczema pustu- 
losum, and disguise the primary eruption; or urticarial 
wheals may be excited. Finally, the skin, after some 
years, gets pigmented, as in phthiriasis, and thickened and 
rough, especially about the legs, and desquamates in places ; 
the hairs of the general surface also disappear. In old- 
standing cases, also, the crural and inguinal glands become 
symmetrically enlarged. The disease usually commences 
in childhood, is very chronic, and frequently lasts the 
whole of life, though it may almost disappear at times, and 
notably in the summer. The sites of attack are the tx^unk, 
the sacral regions, and buttocks, and limbs, especially on 
their extensor aspects. It may extend up the neck to the 
face in some degree, but never attacks the scalp^ the flexures 
of the elbows and knees, the genitals, or axillae. The 
papules are formed by a moderate exudation of cells and 
some fluid into the papillary layer, with secondary hyper- 
trophy of the elements composing the parts, and pigmenta- 



152 DESCRIPTION AND TREATMENT 

tion. Prurigo patients are generally pallid, and often ill- 
nourished, but no definite cause has been made out. 
Exclusive reliance for diagnostic purposes must not be laid 
upon the papules ; but the history of the affection, and the 
sites attacked, should be noted. It may closely simulate 
chronic phthiriasis corporis (formerly called prurigo senilis) 
and scabies, and general chronic papular eczema with some 
admixture of the pustular phase and old-standing xero- 
derma ; but local parasiticide remedies will cure scabies 
and phthiriasis, whilst eczema favors the flexures, and in 
children the scalp and face, and in the young there is more 
pus formation. 

Treatment. — Inveterate cases will exhaust all our reme- 
dies, but much relief may be given by constant alkaline 
and emollient baths (F. 1) ; tar, carbolic acid, or sulphur 
soaps; the inunction of emollient and sedative salves (F. 21, 
26, 29, 42, 86) ; and glycer. amyli or stimulating applica- 
tions (F. 31, 73-8, 35, 62). Internally, the disease may be 
mitigated and held in check by arsenical, ferruginous, and 
mineral acid tonics, fresh air and good food, and cod-liver 
oil. 

Pruritus means a state of itching, and this and allied 
disorders of sensation, such as tingling, formication, etc., 
are common accompaniments, in greater or less degree, of 
a host of skin affections characterized by structural alter- 
ations, such as prurigo, phthiriasis, scabies, urticaria, and 
eczema ; but the term is specially applicable to a condition 
in which there is no primary structural disease of the skin, 
but the itching or disordered sensation is the sole symptom 
present, though the scratching, and rubbing, and tearing 
which it induces may bring about secondarily excoriations 
and various degrees of inflammation, according to the state 
of nutrition of the patient, and the severity of the attack. 
There is direct functional disorder of the nerves, or it is 



OF SKIN DISEASES. 15ij 

reflex from some internal cause, and with these causes may 
be included that from venous congestion. It may be local, 
as about the nose of children affected with worms or other 
gastro-intestinal irritation ; about the genitalia or anus ; or 
more or less generally diffused, and often shifting about the 
trunk and extremities. So, also, it may be slight and 
unimportant, or become a very distressing and serious 
malady ; preventing sleep and w^earing the patient down 
to a miserable condition. It is often worse towards night, 
or in the quietude of the bedroom, or greatly aggravated 
by w^armth, or the contact of colder air on rising in the 
morning. Dr. Duhring and others have described a form 
seated especially about the inside of the thighs and the 
popliteal spaces, distinctly brought about by atmospheric 
conditions, and occurring in the colder months only (P. 
kieinalis). The more important local forms occur in the 
male about the anus, the scrotum, and perineum, and are 
generally traceable to some disorder of the alimentary 
or genito-urinary tract, or to liver disturbance. In the 
female, in addition to this, the genitalia are often the seat 
of distressing irritation, dependent on a variety of dis- 
ordered states of the genito-urinary organs, to gestation, 
irregularities of menstruation, hysteria, etc., and often 
diabetes. True primary pruritus wall have to be distin- 
guished from itching induced by flannel, etc., in contact 
with a sensitive skin, and, where a secondary eruption 
exists, from phthiriasis, scabies, eczema, prurigo, and so on, 
by the sites attacked, the character of the eruption, the 
time of day or of the year when irritation comes on, etc. 
In connection with pruritus, it is well to bear in mind the 
remarkable disorders of sensation associated with tahes 
dorsalis and other diseases of the nervous system, in w^hich 
the sensory tracts in the cord are involved. 

Treatment. — The alleviation of itching, w^hen part and 
parcel of various skin eruptions, will be found detailed 



154 DESCRIPTION AND TREATMENT 

under the respective diseases. The treatment of primary 
pruritus, without structural alteration, is often most trouble- 
some, and taxes all our resources. A most careful sifting 
of all possible causes should be made, and any departure 
from health should be rectified. Thus all hepatic func- 
tional disorders and congestive states of the rectum should 
be set right, and any genito-urinary or menstrual trouble 
remedied. The purely neurotic conditions are those, how- 
ever, which defy treatment most, and remedy after remedy, 
internal and external, may be tried in vain. No rules can 
be laid down, for some patients can bear nothing but the 
most soothing applications (F. 20-22, 64, 83-6), others are 
relieved by cooling remedies (F. 14, 15), or astringents (F. 
40, 79, 90, 93), or mild stimulants (F. 19, 23-25), or 
stronger ones (F. 31, 32, 112, 50, 57, 67, 73-8, 80), or 
alkaline lotions (F. 65, 66), or sedatives (16, 18, 26, 44, 46 
47, 59, 61). Other patients cannot tolerate any greasy 
applications, and in a few the skin is so hyperaesthetic, that 
only water (hot or cold) or gruel bathing is possible. In 
neurotic cases strong nerve tonics should be given, and 
cannabis indica seems to have a decided controlling effect 
on itching in some cases. Occasionally it is necessary to 
try and procure sleep by chloral, bromide of potassium, or 
opium. 

Psoriasis is a non-contagious, usually bilateral, and 
extensively distributed, very common eruptive disease of 
the skin, characterized by the evolution of dusky red, very 
slightly elevated, flat spots or papules of more or less cir- 
cular outline, and of various sizes, covered to the thickness 
of a line with silvery scales, which are pretty easily 
detached, disclosing the hypersemic base. The papules are 
formed probably by a primary hypertrophy of the rete and 
enlargement of the papillae ; the hypersemia of the papillary 
layer and free formation of loose cuticle are secondary. 



OF SKIN DISEASES. 155 

There is no discharge, and itching varies in degree, though 
usually not very marked. Further, it is essentially a 
chronic disease, for the individual papules tend to persist, 
and fresh ones evolve from time to time, and it shows a 
proneness to recur throughout life. The papules first 
appear as dull-red, circumscribed elevations, about the size 
of pin-heads, but faintly scaly, though not polished and 
not angular as in lichen planus {P. punctata). 

As these spots enlarge centrifugally, the scales increase 
in amount, and the eruption has been likened to drops of 
mortar dried upon the skin (P. guttata). Still enlarging, 
the patches reach the size of a sixpence or a shilling, and, 
clearing centrally, tend to assume a circular outline (P. 
nummularis), and as they join with neighboring patches, 
large areas of skin may become covered (P. diffusa). Very 
large ringed patches are called P. annularis vel circinata, 
and constitute the lepra of older authors, and when these 
fuse to form patterns, the name P. gyrata vel figurata is 
applied. Very old thickened and infiltrated fissured 
patches with scanty scaling, closely resembling chronic 
squamous eczema, are called P. inveterata, or if patches are 
secondarily inflamed and weeping, which very rarely 
occurs, the name P. eczemateux has been applied. Lastly, 
in children and some strumous subjects, some cell and 
serous effusion may become mixed with the scales to form 
rupioid crusts (P. rupioides). Many of these forms occur 
together on the same subject. No site can claim immunity 
from attack, but certain regions are particularly afiected, 
viz., the extensor aspects of the elbows and knees, forearms 
and legs, the buttocks, and the scalp. 

Psoriasis is generally of wide distribution, and has a 
certain amount of symmetry, but there may be only a few 
patches, and it may occasionally be quite localized — e. g., 
to the scalp or trunk. In children, even when widely dis- 
tributed, not uncommonly the patches may leave the elbows 



156 DESCEIPTION AND TREATMENT 

and knees unaffected. An important local variety is P. 
palmaris et plantaris, hut this is infinitely rare unassociated 
with the eruption elseivhere, and the chronic papular or 
patchy scaly eruption in these regions is nearly always 
syphilitic, especially when unilateral, and when not eczema- 
tous. 

Psoriasis is common in all ranks of life, and in either 
sex, and may begin at any age, even in infancy. It not un- 
commonly occurs in several members of a family and in 
several generations. The cause of psoriasis is not clearly 
made out, but McCall Anderson's view is possibly a true 
one, that it " is an inherited perverted tendency of tissue 
formation, which tendency lies dormant until called into 
activity by some exciting cause ;" and it is probably not 
due to a special blood condition, or dyscrasia, or diathesis, 
but is due to a peculiar morbid tendency of parts of the 
skin. Some, indeed, from its symmetry, special distribu- 
tion, heredity, tendency to recurrence, and the fact that it 
yields to arsenic, hold that it is one of a group of affections 
due to a special diathesis called the "dartous." The dis- 
ease, though the subjects of it sometimes appear quite 
healthy, may be excited by any cause deranging the health, 
such as dyspepsia, pregnancy, lactation, struma, lymph- 
atism, gout, etc. It appears to be more frequent in the 
spring and autumn. 

Psoriasis must be carefully diagnosed from papular and 
squamous syphilides, squamous eczema, chronic tinea cir- 
cinata, erythematous lupus, lichen planus, and pityriasis 
rubra. The diagnosis must be made after a careful ex- 
amination of the total evidence, for however characteristic 
individual symptoms usually may be, none of them are in- 
fallible. Psoriasis, whether widely or sparsely distributed, 
almost invariably selects as one very favorable site the 
extensor aspect of the limbs, whilst the papular and squa- 
mous syphilides prefer the flexor aspects. Psoriasis is, as 



OF SKIN DISEASES. 157 

a rule, more scaly, and when the silvery scales are removed, 
a hypersemic base is disclosed. The distinction between 
the coppery or raw-ham color of syphilides, and the sombre 
red of psoriasis, cannot always be depended on, nor must 
the annular configuration of a psoriasis lead us astray to 
mistake it for a relapsing syphilide ; yet there is a greater 
tendency to this form in old psoriasis, and syphilides rarely 
attain such a large size. Syphilides in some regions, as the 
forehead, tend to be crustitial, and they are often multiform, 
and relapses get more and more localized. Lastly, we have 
the history of the disease — in psoriasis the attacks perhaps 
dating for years back ; in syphilis the sore, the adenitis, 
sore throat, miscarriages, and so on. 

Lichen planus is a rare disease, and the red, but faintly 
scaly, angular, polished papules, tending to occupy certain 
sites (see L. planus), should not be confounded with psori- 
asis. The disks of Lupus erythematosus, which in the rare 
cases of wide distribution may simulate psoriasis, leave 
little scars by the atrophy of their centres; and when 
localized about the ears, face, and fingers, can hardly be 
confounded. On the scalp, how^ever, patches of L. erythe- 
matosus, with loss of hair, may be mistaken for the disease 
under consideration. They are very persistent and rebel- 
lious to treatment. Old patches of localized chronic thick- 
ened squamous eczema are with difficulty sometimes dis- 
tinguished, but a history of weeping will generally be 
brought out. Red, freely desquamating pityriasis rubra is 
usually universal, which psoriasis very rarely indeed is. 

Treatment. — The first thing to do is carefully to ex- 
amine into the health, and rectify by appropriate remedies 
any exciting or intensifying conditions, such as strum.a, 
lymphatism, and dyspeptic, plethoric, or gouty states ; 
debility of any kind, such as from lactation, irregular 
menstruation, pregnancy, over-work, and sedentary habits, 
etc. ; whilst proper hygiene, exercise, and food are insisted 

14 



158 DESCEIPTION AND TREATMENT 

on. In some acute, widespread, and hypersemic conditions, 
diuretics are called for at first. After these exciting causes 
have been removed, or concurrently in some cases, arsenic 
is a remedy which exercises a powerful remedial influence 
over psoriasis, and, as a rule, the more chronic the stage of 
the disease the more is this drug called for. From three 
to five minims of the liquor arsenicalis {see, however, F. 
139 et seq.) should be given, freely diluted, three times 
daily, after meals, and, if well borne, the dose may be 
gradually increased. The arsenic should be continued for 
some time after the eruption has disappeared. Phosphorus 
is a drug of the same class. Some recommend pow'erful 
stimulating alteratives, such as tar, copaiba, turpentine, 
and carbolic acid. There can be no doubt also that the 
patches can be removed in many cases solely by local ap- 
plications, but internal and external treatment should as a 
rule be combined. It is bat rarely that soothing measures 
are called for, and usually we may proceed to rub in stim- 
ulants and rubefacients, of which a great number are in 
use. Tar (F. 73-8), carbolic acid (F. 31, 75), mercurials 
(F. 52 et seq.) to not too extensive surfaces, turpentine (F. 
82), pyrogallic acid (F. 63), chrysophanic acid (F. 33), 
and naphthol (F. 62), are perhaps the best (see also F. 103, 
104, 106, 113, 114), and thymol (F, 80) is a mild cleanly 
application. It is probable that some of these local appli- 
cations are absorbed, and assist by their alterative effect 
on the system. Where many scales accumulate, it is neces- 
sary to thoroughly shampoo the surface with some soap 
as a preliminary to other application. Indeed, baths may 
be freely used in this affection. 

Purpura is a disease which is usually considered in 
treatises on afifections of the skin, because of the constancy 
and predominance of the skin-lesions, and because the latter 
are often the only symptoms present. It is a non-heredi- 



OF SKIN DISEASES. 159 

tary, sporadic, acquired, transitory disease, characterized 
by simple spontaneous extravasations of blood, and must 
be distinguished from haemophilia, from the purpuric com- 
plications of scurvy, leucocythemia, the acute specific dis- 
eases, etc., and from the secondary hemorrhages due occa- 
sionally to intense local hypersemia and inflammation — 
e. ^., in the erythemata. The color of the lesions differs 
according to the depth at which the extravasations are 
situated, and may be bright red or more commonly purple, 
and as they disappear they go through a variety of tints. 
They are smooth and rarely elevated, and in size they vary 
usually from a pin-point to a finger-nail, but may form 
large sheets, and they do not disappear on pressure. They 
are mostly rounded, but occasionally irregular in shape, 
and appear suddenly and painlessly or with some stinging, 
and often in successive crops, in great numbers here and 
there on the surface, with most frequency on the lower ex- 
tremities and afterwards on the trunk. 

Purpura is a disease seen mostly during adolescence 
(fifteen to twenty years), and females are affected rather 
more often than males. It is usual to artificially distin- 
guish a mild form {Purpura simplex), in which the lesions 
are of small size and limited to the skin, and a more severe 
phase (P. hcemorrhagica, or Werlhoff's morbus maculosis), in 
which extensive ecchymoses may appear, and hemorrhage 
occur from mucous and serous surfaces, etc. The extrava- 
sations may appear suddenly w^ithout prodromata, or there 
may be some slight antecedent fever, headache, anorexia, 
and depression, or these symptoms may be marked. There 
may be some primary or secondary fever, and the hemor- 
rhage induces anaemia. The disease usually runs its course 
in from two to four weeks, but may be continued by re- 
lapses, or occasionally it terminates fatally, by exhausting 
extravasations, profound depression, or complications. The 
cause is not clear; for though it mostly occurs in the weakly 



IGO DESCRIPTION AND TREATMENT 

and ansemic, it is not entirely a disease of cachexia, and 
may be seen in the apparently healthy and robust. Nor 
can it be referred exclusively to poverty, to deficiencies of 
certain kinds of food, and mal-hygiene. And with regard 
to the mode of extravasation, no definite alteration of the 
blood or vessels has been made out. 

Flea-bites, which are occasionally met with in enormous 
numbers, must not be confounded with purpura simplex, 
and it should be borne in mind that purpuric spots may 
appear in syphilis and in diseases of the lymphatic system, 
and during the administration of iodides, and that hemor- 
rhages may take place in a great variety of papular, vesic- 
ular, and bullous eruptions. The purpuric eruption of 
scurvy is distinguished from P. haemorrhagica in being 
preceded by marked cachexia, due to deprivation of cer- 
tain kinds of diet; scurvy also is epidemic, is associated 
with a bluish-red discoloration and sponginess of the gums, 
and the eruption tends to end in ulceration and gangrene. 
Sometimes the extravasations of blood into the skin in 
purpura excite urticarial wheals (P. urticans), where there 
is much gastric disturbance, and this condition should not 
be confounded with hemorrhage into urticarial w^heals 
{Urticaria hcemorrhagica^. There is still a variety of pur- 
pura to mention (some think it a distinct disease) — viz., 
P. rheumaiica, or Schonlein's Peliosis rheiimatica, in w^hich, 
after a few day's malaise, the large joints (e. g., the ankles 
and knees) become painful and sometimes swollen, and 
then purpuric spots appear in these regions or on the trunk 
or elsewhere, whilst simultaneously the joint pains subside. 
It is said not to be really rheumatic, because the aflTection 
never develops into acute rheumatism with endocarditis, 
and the characteristic sweats are absent. 

Treatment. — The mineral and vegetable acids, tincture 
of perchloride of iron, ergot, ergotine injections, acetate of 
lead (gr. i, t. d. s.), oil of turpentine, are used to stay the 



OF SKIN DISEASES. 161 

tendency to hemorrhage, but Immermann is sceptical of 
any great value attaching to any of these drugs, and re- 
serves the iron preparations for the secondary anaemia left 
by the disease. All are agreed that good hygiene, perfect 
rest, a sparing diet, gentle laxatives, and iced fluids, are 
important factors in the treatment. 

Rhinophyma. (See Acne rosacea.) 

Rhinoscleroma is a very chronic, new small-celled 
growth of the corium and subcutaneous tissue of either the 
nose, upper lip, or surrounding parts, the mucous mem- 
brane of the nose, gums, palate, uvula, and even larynx. 
It occurs equally in either sex, and under twenty cases are 
on record, and these have been described almost entirely 
by observers at Vienna. A typical undoubted case has 
not yet been recognized in England. The growth may 
consist of separate nodules, or of a flat, diffused, raised thick- 
ening with well-defined borders. Its color varies from that 
of the normal skin to a reddish-brown, and is distinguished 
from other growths, such as lupus, syphilis, keloid, and 
epithelioma, in being much indurated, never ulcerating or 
pustulating, not degenerating, nor becoming absorbed, nor 
softened, and in resisting all anti-syphilitic and other in- 
ternal remedies. No secondary deposits form, however 
long it continues ; it does not appear to originate in scar- 
tissue, and it is distinct from epithelioma clinically and 
anatomically. Kaposi thinks it most nearly allied to 
small-celled sarcoma. It is not painful unless touched, it 
tends to recur when removed, and it seems to cause little 
inconvenience, except by a peculiar disfigurement at the 
end of the nose, and by blocking of the nose and throat. 

Treatment. — Nothing is effectual except thorough cau- 
terization or removal by the knife. 

14^ 



162 DESCEIPTION AND TREATMENT 

Ringworm. (^See Tinea.) 
Rodent Ulcer. {See Epithelioma.) 

Roseola is a non-contagious, hyperaemic, widespread 
eruption of a rosy hue, which is usually grouped with the 
Erythemata. It is either symptomatic, and then part only 
of certain acute febrile diseases, as rheumatism, vaccinia 
(about seventh day), cholera, variola, cerebro-spinal men- 
ingitis, etc. ; or it is idioj^athic, as seen mostly in children 
(iJ. mfcmtilis), during change of season (i?. cmtumnalis and 
H. (estiva), and in connection with slight stomach derange- 
ment, or it appears to be excited by ascarides, dentition, 
dietetic errors, etc. The eruptions included under this 
term vary widely in appearance. The symptomatic erup- 
tions are often specially localized, as in variola about the 
groins, and often occur in diffuse patches. Idiopathic roseola 
is characterized by discrete spots, from the size of pin's 
points to papules, like erythema papulatum, or large irreg- 
ular patches which may form rings and segments of circles 
(JE. annulata), and be quite urticarial in character (i?. iir- 
ticata). In the smallest kind of eruption the tiny pimples 
are hardly ever quite punctiform as in scarlatina; they are 
never crescentic, though often patchy, and not so mulberry- 
colored as in measles ; still these diseases may be closely 
simulated, and especially as there is often a little general 
disturbance, and some pyrexia, and injection of the eyes, 
nose, and pharynx. The tongue may be clean or coated. 
The child, however, rarely looks ill, though often anaemic. 
It is evident, therefore, the totality of symptoms in doubt- 
ful cases should be carefully balanced in the diagnosis of 
this disease from scarlatina, measles, rotheln, septicsemic 
rashes, and some drug eruptions. 

Treatment. — ^In idioj^athic roseola all that is required 
is a saline and laxative for a few days, as the eruption is 



OF SKIN DISEASES. 1G3 

transitory and lasts only a few hours or days. Locally, a 
calamine lotion is all that is needed, or a cooling astringent 
Avash, such as hazeline. 

Rupia. {See Syphilis.) 

Scabies, or the Itch, is a contagious disease due to 
the presence and burrowing of the Acarus scabiei or itch- 
mite in the skin. The male acarus wanders over the sur- 
face or hides in the natural folds, or beneath scales, but 
the impregnated female burrows into the epidermis, and 
lays her eggs (twenty or more) at intervals for three or 
four months within the intra-epidermic tunnel or cimiculus, 
and ensconces herself, and may be recognized as a tiny 
white speck, beneath a little eminence at the end of the 
tunnel. This burrow looks to the eye like a miniature 
mole-run, and is dotted wdth black specks at intervals, due 
either to excreta or the apertures of shafts leading down to 
the gallery. The tunnel causes a tortuous linear projection 
of the skin generally a few lines long, is pathognomonic, 
and can only be mistaken for a scratch. The eggs prob- 
ably hatch in from five to fourteen days, and the young 
escape on the surface to repeat the life-history of their 
progenitors. Xow, besides this primary feature, there are 
many secondary complications: thus, the entrance of the 
itch-mite into the skin commonly excites inflammation, 
viz., a papule, vesicle, or pustule, or sometimes a bulla ; 
and further, the direct and reflex irritation set up and the 
often widespread sympathetic itching induce scratt^hing 
and rubbing, and a multiform dermatitis, consisting of 
either erythematous blotches, papules (many capped with 
tiny blood-scabs), linear excoriations, vesicles, bullae, and 
pustules forming crusts, ecthyma, boils, or urticarial w heals. 
The amount and character of the secondary inflammation 
set up, will vary widely as the patient is well or ill- 



164 DESCKIFTION AND TREATMENT 

nourished, healthy or cachectic, cleanly or neglectful, and 
with the length of the attack, and the age of the patient. 
Consequently, in dirty cachectic people the disease runs 
riot, whilst in well-nourished people, who wash frequently, 
and so interfere with the burrowing and development of 
the acarus, perhaps only a few papules are excited about 
the forearms, thighs, and abdomen, and no cuniculi can be 
found. In children, with their pyogenic tendencies, an 
extensive ecthymatous pustular or bullous eruption may 
result. Epidemics of this nature occur in workhouses and 
other institutions where children are crowded together. In 
Norway, a neglected chronic form of scabies (S. Norvegica) 
with extensive inflammation and crusting, skin induration 
and pigmentation, has been described, and this severe 
phase has been recognized in tropical and other countries. 

Itching more marked at night is a notable feature of 
scabies, and should always excite suspicion. The disease 
may be contracted at all ages, and in all classes, but the 
habits of children and young adults, and of the poor and 
uncleanly, lend themselves more to the contagion. There 
are certain selected sites of attack which differ somewhat in the 
adult male and female and the child, though in old-standing 
cases the disease may be widespread over the trunk and 
limbs. The face and scalp are only involved in very rare 
cases in children, and then only probably from sympathetic 
irritation. In the adult the acarus favors the soft skin of 
the interdigits of the hands and the wrists, whence it may 
spread to the hands and forearms, the upper line of the 
penis in the male, the axillary and mammary regions of 
the female, the belly and upper and inner parts of the 
thighs. In young children it is frequently seen on, and 
may be confined to, the buttocks and feet. Scabies is com- 
mon in this country, more frequent on the Continent, and 
still more so amongst the dirty cachectic natives of many 
hot countries, where it is known by many local names — 



OF SKIN DISEASES. 165 

e. g., Malabar Itch, Soldiers are peculiarly liable to con- 
tract this disease and phthiriasis, especially on campaigns 
(Array Itch). It may be caught from some animals who 
generally look " mangy," and cleanly adults get it from 
cohabitation with infected people, in travelling on the 
Continent, etc. The diagnosis of scabies, though generally 
easy, is sometimes attended with difficulty, for one cannot 
be absolutely certain of the presence of the acarus unless 
the burrows are found, and this tunnelling is prevented or 
delayed by cleanly habits and certain occupations (e.^., 
washerwomen), and consequently the greatest difficulty is 
experienced in private practice, where, moreover, scabies 
is less suspected. It should not be forgotten, too, that it 
may be only a complication of syphilis, leprosy, etc. After 
the burrows, the most important facts are marked itching, 
worse at night, the infection of several members of the 
family, and the pretty definite distribution of the eruption 
according to age and sex. Phthiriasis corporis is caused 
by lice in the clothes, tends to attack special regions, 
though sometimes widely spread, and is attended by formi- 
cation, creeping, and burning. Pemphigus is simulated in 
children by the formation of only one or two bullae about 
the hands and feet, mixed with the multiform eruption. 
Lichen urticatus (Urticaria papulosa) and true prurigo 
may be confounded with scabies, and also itching sudamina 
about the fingers, and miliaria in hot weather and in rickety 
children. Eczema in all its more chronic forms is, how- 
ever, the disease par excellence from which scabies must be 
diagnosed, and indeed the multiform dermatitis of scabies 
is indistinguishable except by its usually discrete elements, 
its distribution, and absence of cuniculi. 

Treatment. — The objects are to destroy and remove 
the acari and ova by the process least irritating to the skin, 
and then to heal any inflammation present. Consequently 
the selection of a parasiticide from preparations of sulphur, 



166 DESCEIPTION AND TREATMENT 

tar, mercury, carbolic acid, turpentine, iodide of potassium, 
expressed oil of stavesacre, balsams of copaiba, styrax, and 
Peru, petroleum, creasote, and naphthol (F. 103 et seq.), 
must depend on the age, sex, and position of the patient, 
and on the degree of inflammation present. Hardy's rapid 
cure for hospital patients is as follows, and well illustrates 
the chief points to be observed : The body is thoroughly 
dressed with soft soap, and a warm bath taken to open up 
the cuniculi and expose and remove the acari and eggs, 
and then a modification of Helmerich's ointment (F. 105) 
is thoroughly rubbed into all the skin to kill any remain- 
ing acari by suffocation and poisoning, and the patient 
resumes the wearing apparel, which has meanwhile been 
heated to 100^ or 110° C. At the end of three days the 
ointment is washed off, and any dermatitis healed by sooth- 
ing measures. It will be found effective treatment to rub 
in, after the thorough washing, a milder sulphur ointment 
(F. 107) all over the body and limbs, night and morning, 
for three days, meanwhile not changing the under-gar- 
ments. Not too strong and not too long, is a rule to be 
observed in the treatment, as these parasiticides are irri- 
tants, which excite a dermatitis with itching and burning, 
easily mistaken for an intensification of the original disease. 
Styrax balsam (F. 109) is a mild, cleanly, and effective 
parasiticide for children {see also F. 108). Appropriate 
soothing remedies are starch baths, and the calamine lotion, 
or oleate of zinc or bismuth ointment. 

Scleroderma, or " the hide-bound disease," is a some- 
what rare aflfection, characterized by diffuse hardening 
and stiffening of a large tract of skin, so that it looks 
shrunken and frozen, it feels cold, and cannot be pinched 
up from the subcutaneous tissues. It is impossible, indeed, 
to distinguish this diseased skin from that of some of the 
atrophic phases of morphoea, and many observers in this 



OF SKIN DISEASES. 167 

country hold that the two diseases are essentially similar, 
only that the one tends to be diffuse and universal, and so 
often symmetrical, and the other circumscribed and gener- 
ally limited in extent of distribution, and so often uni- 
lateral. It is thus sought to connect, by a long series of 
links, the circumscribed, ^Yell-defined, single-patched mor- 
phoea, often developed in marked relation to the distribu- 
tion of a cutaneous nerve, and presenting either a marked 
hypertrophic stage or not, through the many-patched con- 
fluent raorphoea involving the greater part of the surface, 
with the variety of conditions included under the terra 
scleroderma, for the latter term is applied both to a universal 
morbid condition and one more localized. 

The change commonly commences, unattended with fever, 
about the nape of the neck, or on the two legs or arms, and 
spreads symmetrically, until a large part or the whole of 
the surface is involved, or the change may be limited in 
extent — e.g., to the hands. The diseased process often 
appears to be simply atrophic, and may progress unnoticed 
for a time, but in other cases the skin has been described 
as thickened, even brawny and leathery, and, moreover, an 
cedematous stage has been observed, but whether this is 
primary, or secondary from constricting bands, is not well 
made out. The subcutaneous connective tissues, the fat, 
fascia, aponeurosis, and tendons, may be involved, and 
even arthropathy and bone atrophy result. The process 
seems to consist in an increase and condensation of the 
cutaneous and subcutaneous fibrous tissue, and conversion 
of the fat into fibrous tissue, with subsequent atrophy, but 
the atrophic process, as in morphoea, may be the most 
marked feature from the outset. The induration, shrink- 
ing, contraction, and atrophy cause a painful sense of 
constriction and tightening : on the face, drag on the lids 
and lips ; about the chest, interfere with respiration ; and 
elsewhere, prevent the movements of the joints, and event- 



168 DESCRIPTION AND TREATMENT 

ually cause wasting of the muscles. As in morphoea, little 
dilated venules may be seen coursing over the surface, 
and there may be various degrees of pigmentation present, 
preceding, coinciding with, or succeeding the induration. 
The diffuse nature of the change, its frequent symmetry, 
the absence of any defined border, and of the lardaceous- 
looking hypertrophy, are points relied on to distinguish 
scleroderma from morphoea, but none can be absolutely 
depended on. The temperature and sensibility are not 
very markedly altered. The disease may commence and 
progress in a slow and insidious manner, and even remain 
for long unnoticed, or its onset and spread may be exceed- 
ingly acute. It tends to disappear spontaneously, but only, 
as a rule, after a number of years. Scleroderma occurs 
mostly in women, and in early and middle life. As to its 
cause, it is now mostly attributed to a tropho-neurosis ; and 
though it may be seen in apparently healthy people, there 
is usually a history of exposure, or rheumatic fever, or 
privation. In connection with scleroderma as here de- 
scribed, it is necessary to refer to a somewhat similar and 
well-marked affection of newly born children, called Sclc- 
reraa iieonatoriun, which almost always ends fatally. It is 
usually generalized, and spreads from the limbs, for in- 
stance, over the surface, and is su})posed by many to be of 
a different nature to the scleroderma of more advanced 
age, in that the indurated, tense condition of the cutaneous 
and subcutaneous tissues seems to be due to a peculiar 
kind of oedema and setting of the fat. 

Treatment. — Continued warm baths and shampooings, 
and the infriction of cod-liver and other oils, afford relief, 
and are grateful remedies. Electricity also may be tried. 
The three cases of universal scleroderma which I have 
had under treatment very gradually improved from a piti- 
able condition under the internal administration of cod- 
liver oil, tonics, and small doses of arsenic, but it must be 



OF SKIN DISEASES. 169 

remembered that the disease tends to get well spontaneously 
in time. 

Scrofuloderma is a term which is used to denote the 
inflammation of the skin directly arising out of the scrofu- 
lous diathesis ; but it has a different significance for many, 
for whilst some draw a distinction between it and lupus, 
holding the latter not to be an outcome of scrofula (scrofu- 
lide), others manifestly include cases of lupus associated 
with a strongly marked scrofulous habit. Consequently 
there is often much confusion as to the application of the 
term scrofuloderma. By it is here meant the chronic, 
boggy, unhealthy inflammation of the skin, different in 
aspect from lupus, with a tendency to suppurate and ulcer- 
ate and crust, forming ragged ulcers, with very irregular, 
undermined edges and an uneven base, and without dis- 
position to heal, discharging a watery pus, and, when 
healed, leaving ugly, disfiguring cicatrices. The inflamed 
skin is usually also of a peculiar livid tint, and the 
scrofulous habit is marked. The commonest form starts 
from an inflamed gland, especially about the neck, and 
thence the skin becomes implicated. It may, however, 
arise independently of a gland, and then is, certainly with 
difficulty, distinguished from lupus in a very scrofulous 
subject. It starts, however, from a phlegmon or gumma- 
tous-like inflammatory mass, and not from an aggregation 
of nodules, characteristic of lupus vulgaris. There is 
another form of scrofuloderma consisting of rounded or 
oval collections of pus, perhaps as big as a walnut or egg, 
disseminated about the body (phlegmonous scrojulides). 
These present as doughy swellings over which the skin is 
at first unaltered ; but it gradually becomes inflamed, and 
the abscess discharges. Some of these scrofulodermata in 
adults closely resemble the tertiary syphilitic neoplasms, 
especially if there is bone disease, but the edges of the 

15 



170 DESCRIPTION AND TREATMENT 

ulcers are less clearly defined and sharply cut ; and in 
children the rare jMegmonous syphllides. 

Treatment. — Internally, cod-liver oil, iodine, and fer- 
ruginous preparations, fresh vegetables, and sea air are 
important restoratives ; whilst locally the unhealthy sur- 
faces, after removal of the crusts by oil poultices, may be 
cleansed and healed by iodoform (F. 37), and iodide of 
starch-paste (F. 36), or later, by balsam of Peru, or a 
mildly stimulant and antiseptic lotion. 

Seborrhoea signifies a functional disorder of the seba- 
ceous glands, not usually attended by hyperemia of the 
surface, and characterized by the accumulation upon the 
surface of the skin of an excessive amount of altered 
sebum. It frequently persists from birth about the scalp 
of infants, and may occur at any age, but is especially 
frequent about puberty, and is more common in females. 
So also it may affect any portion of the body where seba- 
ceous glands exist, but is seen in by far the majority of 
cases on the scalp, and next on the face, and on the upper 
part of the trunk it is far more rare. 

The subjects of seborrhoea are almost invariably anaemic 
or chlorotic, and debilitated, and have a bad circulation. 
Sometimes it is distinctly traceable to lowered nutrition 
after a fever, but not infrequently there is a strong family 
history of delicacy or pronounced phthisis. Two forms are 
described; one, a rare manifestation, seen generally about 
the face, in which the excessive sebaceous flow is fluid, 
giving the skin a greasy aspect, or sometimes collecting in 
drops {S. oleosa) ; and a second common form in which the 
sebum collects in concrete masses mixed with epithelium 
freely shed from the sebaceous ducts and glands. In in- 
tensity this second form varies widely from a simple pity- 
riasic condition (dandriff) to a state in which the shafts of 
the hairs are ensheathed for a good part of their length by 



OF SKIN DISEASES. 171 

the fatty masses, which bind the hairs down in a caked 
mass. It is a peculiarity of the disease on the scalp that it 
affects pretty nearly the whole surface uniformly, sometimes 
spreading on to the forehead, and that when the greasy 
plates are removed, the skin surface is not raw and weeping 
as in eczema, but generally of a dull leaden tint. Sebor- 
rhoca sicca less frequently attacks the face, and the more or 
less discolored delicate fatty plates adhere to the surface, 
which is often hypersemic, especially about the follicles. 

The disease does not give rise usually to much irritation, 
but on the face the patches are hot and uncomfortable. 
On the scalp the diagnosis from eczema has been already 
pointed out ; and here it not infrequently complicates dif- 
fuse tinea tonsurans, and the diseased hairs are hidden by 
the fatty plates. About the face the greasy character of 
the crusts, the absence of infiltration and weeping, and the 
special implication of the ducts, should distinguish it from 
eczema; but the early stages of lupus sebaceus, before 
scarring has occurred in the centre of the patches, are with 
difficulty distinguished from isolated patches ; indeed this 
form of lupus may supervene on seborrhoea. On the chest 
and back it may closely simulate tinea circinata and versi- 
color. 

Treatment. — Constitutional remedies are certainly re- 
quired, and nothing is more effective than cod-liver oil, 
whilst the anaemia and debility must be combated by iron 
preparations and suitable tonics. Locally all crusts should 
be removed by soaking in oil, and the scalp thoroughly 
washed every few days with an alcoholic solution of soft 
soap (F. 68), or a stimulant soap — e. g., carbolic, sulphur, 
or tar, or a bicarbonate of potash solution (^ss-jj to aq. §ij). 
Immediately following the shampooing, and in the intervals, 
an astringent (F. 79, 40, 42, 13) or mild stirbulant (F. 52- 
55, 31, 32, 25, 30) must be well inuncted. A mildly stim- 
ulating treatment also suits the seborrhagic patches of the 



172 DESCRIPTION AND TREATMENT 

general surface as a rule, but occasionally in both cases 
simple soothing remedies are called for (F. 20, 64, 84, 
85, 86). 

Septicaemic and Pyaemic Eruptions. — It is gen- 
erally held that puerperal women and persons, especially 
children, after accidents and surgical operations, are partic- 
ularly prone to acquire scarlatina, and that the symptoms 
of the fever in these circumstances may develop with 
abnormal rapidity. It is also certain that the classes of 
persons before mentioned not infrequently suffer from a 
non-contagious scarlatiniform eruption, which it is impos- 
sible in many cases to distinguish from true scarlatina. 
The eruption develops quickly after the accident or opera- 
tion, is not usually universal, does not last, as a rule, more 
than twenty-four hours, is not accompanied by high fever, 
strawberry tongue, or more than a slight congestion of the 
throat, and is often not intense enough to occasion desqua- 
mation. It must not be confounded with the sudamina and 
miliaria of the puerperal state. This surgical erythema 
has also been noticed to depend on a local abscess, and very 
rarely on internal suppuration (hepatitis, empyema). In 
pycemia, also, a pustular eruption, accompanied or not by 
cutaneous ulceration and abscess, has been described, but 
such cases must not be confounded with the peculiarly 
insidious onset of glanders and farcy. 

Shingles. (See Herpes zoster.) 

Strophulus, or Red gum, is a term which has long 
been used to denote an eruption of soft red pimples or 
papules in infants, and it is probable that it includes several 
distinct pathological conditions. Certainly the majority of 
these rashes appear to be of the nature of miliaria rubra, 
and to be hypersemic sweat glands caused by the overheat- 



OF SKIN DISEASES. 173 

ing and wrapping up of the child, or the excessive sweating 
so common in rickets, disorders of the alimentary canal, 
and teething. Strophulus volatlcus (Willan) was the name 
given to the fleeting pink blotches of urticaria seen in 
children. The eruption is usually situated about the face 
and arms, and must not be confounded with the erythe- 
matous papules of hereditary syphilis seated about the 
genitalia and buttocks. The term S. albidus was formerly 
applied to the small pearly white specks seen about the 
face of children, and due to distended sebaceous glands 
(^see Milium). 

Treatment. — If due to excessive swaddling and heating, 
this should be rectified ; and if to excessive sweating, the 
cause must be unravelled, and any stomach disturbance 
put right by regulation of the diet, and laxatives, and pre- 
vention of griping; or, if due to rickets, this should be 
treated accordingly. Locally, a lead or calamine lotion 
(F. 44, 83) is sufficient. 

Sudamina, or Miliaria crystallina (Hebra), is a 
term applied to a non-inflammatory disorder of the sweat 
apparatus, characterized by the retention of sw^eat, which 
collects in the skin as little pellucid or opalescent, tense, 
globular, or oval, itchy, discrete vesicles, scattered irregu- 
larly or crowded together, fairly uniform in size, and form- 
ing rapidly and in successive crops. Each vesicle collapses 
in two or three days. The retention seems due to the 
sudden, or unusually profuse, formation of sweat, whilst its 
outflow is impeded by clothing, or the pressure of the bed ; 
hence the eruption is seen commonly in many febrile states, 
such as acute rheumatism, pysemia, lying-in, and puerperal 
fever, agues, etc.; also in rickety children, and in hot 
climates, and in this country in the summer months scat- 
tered about the hands. There is some difference of opinion 
as to the exact site and method of formation of the vesicle 

15- 



174 DESCRIPTION AND TREATMENT 

— viz., whether the distended duct itself forms the vesicle, 
or whether the sweat oozes out and collects around the 
duct; also as to whether this takes place between the 
layers of the cuticle, or at the junction of the cuticle and 
Malpighian layer. Sudamina must be distinguished from 
eczema vesicles, which occur in groups on an infiltrated 
patch of skin and become confluent ; and about the hands 
from scabies vesicles. 

Treatment. — Usually not any is required, but the 
tiresomely itchy vesicles occurring about the hands may be 
pricked, and their recurrence prevented by tonic treatment. 

Sycosis is a chronic, non-parasitic, and non-contagious 
inflammation of the hair-follicles and peri-follicular tissues, 
evidenced by the formation of red acneiform papules, pus- 
tules, and nodules, or houtons, around the hairs of the 
whiskers, moustache, or beard. There may be considerable 
itching, burning, or smarting, and if the patient shave 
much distress is caused. The intervening skin may be 
much swollen, and sometimes the pustules, which are 
usually discrete, are so closely studded over a part that an. 
extensive crust is formed. The inflammation is usually 
symmetrical aud widespread,- though it may be limited 
altogether to one side or one region, as the upper lip, or only 
for a time. When long-continued, the growth of the hair 
may be considerably interfered with. As for the cause, it is 
impossible in some cases to find a clue, but generally the 
patient is markedly debilitated, and especially dyspeptic. 
Sycosis must be diagnosed from tinea sycosis {Sycosis 
parasitica), a rare disease in this country, though sometimes 
contracted from cattle and in the barber's shop. In ordi- 
nary tinea sycosis there is usually a history of an early 
circinate spreading ringworm, and the disease is long 
asymmetrical, and later the hairs present all the characters 
of those in tinea tonsurans. In the form contracted from 



OF SKIN DISEASES. 175 

cattle the inflammation is very severe. Eczema of these 
hairy parts may also simulate sycosis, but the hairs are not 
specially involved, and there is free exudation of serum. 

Treatment. — Internally the digestion and assimilation 
of the food must be thoroughly set right, by bismuth, 
alkalies, acids, bitters, and pepsine, as occasion requires, 
and the strength built up by aperient tonics and cod-liver 
oil. The habits also, with regard to excessive or ill-timed 
smoking and indulgence in alcohol, and regulation of the 
bowels, must be specially attended to. In chronic infil- 
trated cases, an alterative such as Donovan's solution (F. 
135) is useful, but arsenic has no specific influence. 
Locally, after removal of the crusts, the disease should be 
treated as a simple inflammation by the soothing oleates 
(F. 20, S6, 85), or a lead or calamine lotion (F. 45, 83), 
and gradually the number of pustules evolved grows less 
and less. If very chronic, or if the skin be infiltrated, it 
is well for a time to rub in thoroughly at night some 
stimulant and resolvent salve (F. 69-72, 52-55). The 
hair should be kept cut short, and epilation sometimes 
afibrds relief if there is much pustulation, but the degree of 
pain caused by this process and its good eflfects vary widely. 

Syphilodermata, or Syphilides, comprise the 
manifold manifestations of syphilis in the skin, a structure 
which is especially prone to attack in this disease, although 
no organ or tissue can claim exemption from the liability 
to be involved at some period of the evolution of the dis- 
ease. The specific poison of syphilis is taken into the 
system from a local inoculation, and manifests its presence 
by setting up a peculiar inflammatory process in various 
parts of the body. The symptoms are usually grouped 
clinically into three stages — viz., the primary, or "those 
developed at the point of contagion;" the secondary, or 
those immediately succeeding the distribution of the poison 



176 DESCRIPTION AND TREATMENT 

through the system, usually widespread and mainly limited 
to the superficial structures; and the tertiary, or later 
symptoms, which are more localized, and tend to affect a 
deeper set of structures. A syphilitic attack practically, 
as with smallpox, protects the sufferer from a second attack, 
and the intensity of the dis^ease varies widely with the con- 
stitutional habit and state of nutrition of the subject — e. g,, 
its effects are much exaggerated in all ill-nourished condi- 
tions of body and in the intemperate. The sources of 
infection are the secretion from, and products of disintegra- 
tion of, the primary sore, the discharges from the secondary 
eruptions, and the blood in the secondary stage, and the 
disease cannot be contracted from milk, saliva, urine, sweat, 
tears, or leucorrhoeal discharge. Vaccination may be 
a means of inoculation. The poison must be brought in 
contact with an abraded surface, though it is said that 
w^omen, w^hen syphilized through the medium of a diseased 
foetus, develop no primary sore and no early secondary 
symptoms, but gradually get anaemic and debilitated, 
whilst alopecia, adenopathy, psoriasis palmaris, and ulcer- 
ated throats supervene till the tertiary evidences appear. 
Syphilis must be considered in its acquired and her edited 
manifestations, as these present some differences. 

Acquired Syphilis. — After the inoculation of the 
syphilitic virus there succeeds a period of apparent quies- 
cence, both h^cally and generally, which is called thej^erwd 
of incubation, and any little excoriation or temporary 
inflammation or ulceration caused by irritant discharges 
tends to heal. After this period, ranging from ten to fifty 
or more days, but usually about twenty-five to twenty-eight 
days, the j^rimary evidences of infection appear at the seat 
of inoculation — viz., the "initial sclerosis'' or "primary 
lesion," due to infiltration of the superficial meshes of the 
cutis with small round nucleated cells like leucocytes. 



OF SKIN DISEASES. 177 

The exact appearances differ, for the infiltration may occur 
about an obstinate excoriation, or be diffused in the skin, 
or a rounded, flat, copper-colored thickening, or papule, 
may form and reach the size of a sixpence or shilling, and 
remain thus without particular symptoms, or desquamate, 
or it usually becomes superficially eroded in the centre and 
exudes a slight thin discharge, or becomes covered with a 
deposit like sodden chamois-leather. The sides of this 
"hard chancre'' (Hunterian) are peculiarly hard and 
indurated, rounded and bevelled, the edges adherent, and 
the lesion but little vascular. This initial lesion must be 
carefully distinguished from the non-syphilitic "soft chan- 
cre" or chancroid, which usually commences within a week 
after infection, is often multiple, forms a comparatively 
deep, painful, inflamed ulcer, with sharply cut free edges, 
dirty gray base, and free discharge. The diagnosis is 
difficult when the two are coincident. It must not be con- 
founded either with the multiple, itchy, short-lived inflam- 
matory vesicles of herpes preputii. 

A syphilitic chancre may occur on all sorts of sites — e, g., 
on the lip, and there simulate epithelioma, but naturally 
most frequently on the genitals. The next symptom of 
the primary stage is the chronic indolent enlargement of the 
group of lymphatic glands in immediate connection with 
the primary sore, following the latter in about five to ten 
days. About seven wrecks after the commencement of the 
initial sclerosis, and ten weeks after inoculation, the sec- 
ondary or exanthemic or constitutional or condylomatoiis 
period commences by malaise, shiverings, anorexia, flying 
pains, headache, irregular febrile disturbance, more gen- 
eral adenopathy, and anaemia, and tends to last from six to 
twelve months. The eruptions correspond more or less 
closely to the roseolous, papular, scaly, vesicular, and 
bullous types, and tend to evolve slowly, to gradually die 
out spontaneously, and to recur either according to a 



178 DESCRIPTION AND TREATMENT 

similar or different type. They rarely ulcerate unless the 
state of nutrition is very low. These eruptions may evolve 
within the mouth, and in this stage an erythema of the 
fauces also occurs, ending in the formation of small, 
rounded, cleanly cut ulcers, evincing no tendency to spread. 
Iritis, which may relapse, and, less frequently, choroiditis 
and retinitis, may be also seen. About eighteen months 
after infection, the period of latency ensues, and lasts from a 
few months to twenty years or upwards, during which time 
the patient may be free from, or bothered from time to 
time by, eruptions on the skin, more limited in site and 
less symmetrical than the secondary eruptions — e. g., so- 
called psoriasis palmaris et plantaris, and by ulcers on the 
tongue or buccal mucous membrane. Following this 
variable period come the tertiary symptoms, characterized by 
their greater proneness to relapse, their asymmetrical ten- 
dency, their disinclination to spontaneous disappearance, 
their deeper affection of the tissues, and tendency to attack 
more deeply situated structures. The skin is less promi- 
nently affected than in the exanthemic stage, and the new 
growth there seems more concentrated in nodules, and so 
often necroses, but does not cause any enlargement of the 
related lymphatic glands. In addition, localized low inflam- 
mations of connective tissue occurs — e. g., in the periosteum 
of the long bones and of the skull, and in the capsules and 
interstitial tissue of the viscera; also characteristic tumors, 
known as gummata, ranging up to a walnut in size, 
especially affecting the subcutaneous tissue, the submucous 
tissue (e. g., palate and pharynx), muscles, fasciae, bone, 
and visceral connective tissue. This new growth, from its 
condensation and bulk, tends to end in degenerative 
changes, and in the skin and mucous membrane shows 
a marked tendency to break down into ulcers, which 
cicatrize in the centre, whilst the growths spread at the 
periphery to assume a ringed or crescentic form. 



OF SKIN DISEASES. 179 

111 proceeding to consider the syphilides more in detail, 
we must point out that, though they present an infinite 
variety of aspect, yet they are usually characteristic iu 
appearance, by reason of possessing distinctive common 
family characters, not one of which is invariably present, 
yet many of them constant and associated together. Each 
type of syphilide has its hour in the natural evolution of 
the disease ; but the stages of the evolution may be " forced '' 
or retarded by constitutional peculiarities and other influ- 
ences. The early syphilides tend to become generalized, 
disseminated, copious, symmetrical, and affect the skin 
superficially; the later ones less copious, less generalized, 
and less symmetrical ; whilst in the tertiary stages the skin 
is deeply afiPected, there is more proneness to ulceration, 
and little symmetry and generalization, though often both- 
sided. Their slow evolution and indolent character are 
associated with the absence of marked itching and burning, 
except in the roseolous type, and distinguish them from the 
acute exanthems and exudations. A remarkable dull red- 
dish-brown, copper, or raw-ham color usually characterizes 
them, though this color maybe occasionally ill-defined or ap- 
proached by other non-syphilitic eruptions. Their form or 
arrangement is peculiar, for the eruption tends to be grouped 
in a circular or crescentic manner, though this configura- 
tion may be seen in chronic psoriasis, ringworm, erythema, 
pemphigus, leprosy, etc. Further, owing to their slow 
evolution in relays, their indolence, and the fact that one 
type may be succeeded by another, a syphilitic eruption 
frequently shows a polymorphism which is only approached 
by one or two other affections, such as eczema and scabies 
— e. g.y macules, papules, pustules, and ulcers may exist 
together. The peculiarities of the scales, crusts, cicatrices, 
and ulcers, and the sites of selection, will be further re- 
ferred to. 



180 DESCRIPTION AND TREATMENT 

The Macular or Roseolous syphilide (Syphilis 
maculosa sen erythematosa^ is the earliest to appear, and 
frequently passes away unnoticed, unless very copious or 
irritable. It occurs usually about the sides of the abdomen 
and thorax, or over the trunk, as erythematous macules, 
rose-colored at first, and fading on pressure, but later duller 
and eventually tawny, or they fade away leaving a brownish 
stain, hardly raised as a rule, in size from a lentil to a pea 
or shilling, usually discrete, and mostly rounded or ap- 
proaching it, or rarely in crescents. It takes some days to 
evolve, and is usually indolent, lasting two or three weeks. 
It may be confounded with any macular erythematous 
eruption — e. g,, simple roseola, measles, and other acute 
specifics, erythema multiforme, urticaria, tinea versicolor, 
and medicinal rashes, and corroborative signs of syphilis 
in the throat and elsewhere must be carefully sought for. 

The Papular syphilide (Syphilis cutanea papulosa) 
presents much variety of aspect, but all phases are charac- 
terized by a marked infiltration of the papillary layer, 
either immediately around the follicles or elsewhere, pro- 
ducing a solid elevation of the skin. The chief varieties 
are as follows : The small or miliary papular syphilide, or so- 
called syphilitic lichen, is a precocious uncommon form, and 
consists of shotty, rounded or acuminate, smooth or finely 
scaly papules, varying in size from a pin's head to a small 
pea, and disseminated irregularly or grouped corymbosely 
or in circular areas. Some papules may be capped by a 
little collection of serum or pus, thus passing into the 
miliary pustular or acneiform type. It may be confounded 
with lichen scrofulosorum particularly, and circumscribed 
papular eczema; but it rarely occurs without an admixture 
of larger papules and coincidence of other syphilitic 
symptoms. The large papular or lenticular syphilide is a 
very common form, and, whilst usually following closely on 



OF SKIN DISEASES. 181 

the roseolous eruption, it frequently relapses, and may recur 
more or less localized for years. The eruption consists of 
flattened, circular, or oval, coppery, indolent papules, in 
size from a split pea to a sixpence, discrete or fused into 
patches, and with only very fine scales, if any. The papules 
may be further disk-like (iiummular papidar syphilide) or 
circinate, or moderately scaly (^psoriasiform syphilide or so- 
called syphilitic psoriasis), or slightly crusted and eroded, 
especially about the forehead or hairy parts {papido-crusti- 
tial syphilide), or warty from papillary hypertrophy (the 
vegetating or frambcesioid syphilide). The site on w-hich 
they occur has much influence in modifying their aspect; 
thus on mucous or muco-cutaneous surfaces and in moist situ- 
ations — e, g., beneath folds of skin, flexures of joints, between 
fingers and toes, beneath prepuce and labia, and about the 
perineum and anus, they occur as soft, flattened, auto- 
inoculable elevations wdth broad bases, often fused into 
masses, exuding a viscid secretion, and known as mucous 
tubercles, or patches, or cond.ylomata lata, to be distinguished 
from other non-syphilitic warty growths. About the corners 
of the mouth or between the toes they may become fissured 
or ulcerated (rhagades), and in the mouth the soddened 
epithelium presents a silvery aspect, and on the palms and 
soles the thick epidermis modifies the eruption (the so-called 
syphilitic palmar or plantar psoriasis), so that it closely re- 
sembles ordinary eczema or psoriasis. 

The earliest papular syphilides tend to be widely dis- 
tributed, but the relapsing forms are prone to select the 
forehead, along the margin of the scalp (corona veneris) 
and temporo-frontal region, the nape of the neck and oc- 
ciput, about the mouth and nostrils, the flexor surface of 
the extremities, the genitals, the groove between the but- 
tocks, and the palms and soles. The large papular syphilide 
must not be confounded with psoriasis, and the diagnosis 
must be made after considering the total evidence, for in- 

16 



182 DESCEIPTION AND TREATMENT 

dividual symptoms are not infallible guides. Psoriasis is 
often heredited, and begins in early life, recurring fre- 
quently; syphilis is acquired in adult life. Psoriasis 
especially affects the extensor aspects of the limbs, and 
particularly the elbows and knees, buttocks, and scalp; 
syphilis the flexor surfaces. Psoriasis papules are little 
elevated, except for the large imbricated, silvery, heaped- 
up scales which, w-hen detached, expose bleeding points; 
syphilis papules are more elevated from the cell-infiltration, 
scantily covered, if at all, with, delicate, dirty scales, which 
when removed disclose no bleeding points. The color is 
often deceptive, but psoriasis papules are of a less sombre 
red; syphilis papules frequently show^ some multiformity 
of aspect (crustitial, condylomatous) in dififerent sites. 
Relapsing syphilides are frequently annular, and tend to 
get more and more localized, but only chronic psoriasis 
acquires the annular form, and the rings may attain a 
large size. With regard to localized palmar and plantar 
psoriasis, w-e may set it down that ordinary psoriasis prac- 
tically never occurs limited exclusively to the palms or soles, 
and eczema rarely, also; and further, when they do occur 
in this situation, the aflTection is bilateral. Relapsing pap- 
ular syphilides frequently remain localized to the palms or 
soles and unilaterally. The characteristic smooth, flat, 
pale or generally red, angular, shiny, small papules of 
lichen planus occurring about the limbs, neck, and trunk, 
are frequently set down to syphilis, because they do not 
tally with psoriasis, and the characteristic eruption is as 
yet not widely known. 

The Vesicular syphilide need only be mentioned to 
say that it is an affection of very great rarity. 

The Pustular or Pustulo-crustaceous syphilide 
(Syphilis cutanea pustulosa) presents great diversity of 



OF SKIN DISEASES. 183 

appearance, owing to differences in the size of the lesions, 
the degree of purulency of their contents, and their arrange- 
ment and distribution. These eruptions may be con- 
veniently grouped around certain types, such as acne, 
herpes, varicella, variola, impetigo, and ecthyma. The 
acneiform or miliary pustular syphilide, which closely simu- 
lates acne, is to be associated with the miliary papular 
form. It is uncommon, frequently coexists with the papu- 
lar form, and is an early eruption. It consists of hard, 
copper-colored papules, commonly developed around the 
follicles, varying in size from a pin's head to a split pea, 
and surmounted by a little collection of pus, which dries 
up into a little crust or thick scale, leaving on its fall a 
slight scar. This eruption may be widely sown or more 
localized, and occurs disseminated or in groups. It must 
be distinguished from general acne cachecticorum, iodide 
of potassium acue, varioloid, and artificial acne, and in its 
localized relapsing forms about the face, forehead, and 
scalp, from ordinary acne and A. varioliformis. The vari- 
celliform and varioliform syphilides are also closely allied 
to this, and cannot easily be distinguished by w^ords, but 
the shotty base is less in proportion to the fluid, and the 
whole has less resemblance to acne, though they have to be 
carefully distinguished from cases of pemphigus with little 
bullae, and from scabies. The impetiginous syphilide is so 
called from its resemblance to the small patches of pustular 
eczema (impetigo). The pustules, which appear as such, 
are short-lived, grouped together on a coppery, infiltrated 
base, and a crust rapidly forms. It is comparatively a 
late form, like the ecthymatous syphilide, and tends to be 
localized about the face, genitals, and scalp. In broken- 
down subjects there is a good deal of ulceration and scar- 
ring. The ecthymatous syphilide resembles ordinary ecthyma, 
and consists of short-lived, isolated, and disseminated, scanty, 
flat pustules, varying in size from a pea to a cherry, arising 



184 DESCRIPTION AND TREATMENT 

on a copper-colored base. A thick, dirty, greenish or 
brownish crust quickly forms, beneath which ulceration 
may proceed, and be of a very deep and spreading char- 
acter in cachectic subjects. It is very difficult to separate 
this from the bullous form, and they may be considered 
together, though any eriqotion like ordinary pemphigus in 
acquired syphilis is excessively rare. The more severe 
varieties occur at the end of the secondary, or in the 
tertiary period ; and in these late forms the spreading 
ulcer adds layer after layer of scab from beneath, so that 
a stratified cone-shaped large crust is formed of highly 
characteristic aspect. This variety is known as Rupia. 
The diagnosis of the earlier superficial forms is from simple 
ecthyma, or discrete pustular eczema occurring in cachectic 
subjects. 

The rare Pigmentary syphilide is indistinguishable 
from a delicate leucoderma, and occurs in women especially 
in the late secondary period about the neck, and sometimes 
more extensively. It is not to be confounded with the 
marked stains left by all syphilitic eruptions. 

The Tubercular or Nodular syphilide is common 
after the second year, but gets less frequent after the sixth 
or seventh, and is accompanied usually by marked cachexia. 
It presents as more or less rounded, circumscribed, firm or 
even hard nodules in the skin, varying in size from a pea 
to a bean or larger, of a coppery or livid hue, evolving in- 
dolently and painlessly. There are two varieties, viz., the 
non-ulcerating, or resolutive, with smooth, shining, rounded 
nodules, but rarely desquamative or crustitial, evolving in 
crops over neighboring regions, and so appearing to w-ander ; 
discrete or arranged in characteristic circular, reniform, or 
serpiginous groups, which disclose the nodular character 
only at the margin, and occurring about the face, espe- 



OF SKIN DISEASES. 185 

cially on the bottom of the neck behind, or about the 
sternal and gluteal regions ; and secondly, the ttlcerative, 
which is only the first form broken down into ulceration. 
This ulceration may be comparatively superficial, or deep 
and perforating, destroying the nose or other such parts. 
A single tubercular syphilide of the face might be mistaken 
for a rodent ulcer, and circinate non-ulcerating groups are 
sometimes confounded with patches of chronic psoriasis. 
The coppery color of the nodules, the grouping, the fre- 
quent occurrence on the face, and the muddy cachectic 
aspect, make the diagnosis from lupus vulgaris sometimes 
difficult. Lupus vulgaris begins, as a rule, in early life, 
and the nodules are softer, of a lighter-red color, more 
gelatinous-looking, and they are really formed by the con- 
fluence of tiny deep seated points. The kidney-shaped 
crescent of the syphilide is not assumed by lupus. Wide- 
spread discrete nodules may closely simulate tuberculated 
leprosy. 

Syphilitic gummata of the skin rarely occur before 
the third year, and commonly much later still. Usually 
not more than two or three are found together, and their 
favorite sites are the face, scalp, and extremities about the 
joints. They grow from pea-sized, firm, rounded nodules, 
and reach the volume, perhaps, of a horse-chestnut. They 
are at first elastic, circumscribed, and freely movable. 
Where there is much loose connective tissue, the skin is 
only rendered livid ; but if confined beneath by bone, they 
project as ovoid swellings, and the skin becomes implicated, 
and an ulcer forms with steep punched-out edges and an 
uneven foul base, discharging an offensive ichor. Such 
multiple ulcers about the upper or middle third of the 
leg are very characteristic. Sometimes the gummata are 
diff'use. They must be diagnosed from scrofuloderma and 

16* 



186 DESCRIPTION AND TREATMENT 

multiple tumors such as fibromata, lipomata, sarcomata, 
carcinoraata, and lymphadenomata. 

Syphilitic alopecia is brought about by the general 
state of malnutrition in the early secondary and later 
periods, and is generally diffuse, and also by infiltration of 
the scalp by the neoplasm, and then it is patchy. If the 
alopecia is universal, the scalp may have a polished aspect. 

Syphilitic onychia and perionychia occur also 
from the cachexia, or from infiltration of the root or matrix 
by syphilitic new growth, which may break down into 
ulceration. Perionychia is often associated with rhagades, 
and foul piinched-out ulcers between the toes. 

Hereditary Syphilis difiers from the acquired form 
in the absence of the initial lesion and its concomitants, 
and to some extent in the mode of evolution, inasmuch as 
the symptoms characteristic of the several stages frequently 
overlap one another irregularly — e. g., gummata, visceral 
and bone lesions may occur in intrauterine life, or coincide 
wdth symptoms characteristic of the secondary or exanthemic 
stage of the acquired disease. In other respects, allowing 
for variations due to anatomical and physiological pecu- 
liarities of the infantile skin, the course of the disease is 
very similar, and the skin-lesions analogous. The early 
eruptions tend to be copious, widespread, superficial, and 
symmetrical, and the relapses and later lesions are more 
localized, asymmetrical, and afiect the tissues deeper. The 
early eruptions may be erythematous, papular, or pustular, 
whilst the later lesions are more tubercular or nodular and 
gummatous. Polymorphism is common. Hereditary syphi- 
litic eruptions, as with other infantile skin-lesions, are less 
indolent and apyretic than in the adult, and there is a 
greater tendency to the formation of pus. 

The consequence of the embryo being syphilitic is to 



OF SKIN DISEASES. 187 

cause abortion in about one-third of the cases, owing to the 
death of the foetus, etc. The month of pregnancy at \yhich 
this happens, and the number of successive abortions, vary 
materially with the activity of the poison in the parents, 
and the consequent degree of syphilization of the embryo 
and time of the death of the foetus, etc. Of syphilitic 
children born alive, 24 per cent, die in the first six months, 
it is said, from the intensity of the disease, visceral lesions, 
general failure of nutrition, or intercurrent mischief. An 
aborted foetus has a macerated, easily separable, livid skin, 
without any eruption, or a bullous one usually confined to 
the palms and soles. It is exceptional for a living syphilitic 
infant at its birth to bear traces of any syphilides, but if it 
does, the prognosis is unfavorable. A syphilitic child is 
often remarkably healthy-looking, but in from one week to 
three months, and commonly about a month after birth, the 
child gets peevish and irritable, and acquires a catarrh of 
the nasal mucous membrane ("snuffles''), not to be con- 
founded with non-specific infantile coryza. Symmetrical 
syphilides appear, especially about the upper part of the 
thighs, genitalia, and buttocks, and may gradually extend 
over the body and face. 

These syphilides are usually of an erythematous macular 
character, often mingled with soft papules (not to be con- 
founded with intertrigo of infants from irritating discharges, 
etc.), or they may closely correspond with the difiTerent 
varieties of papular eruption seen in the adult, but moist, 
crustitial, pustular, and ulcerating eruptions are relatively 
more common. The characteristic raw-ham color of the 
eruptions is usually marked. Sometimes the greater part 
of the surface is covered wath sheets of dull red, shiny, 
erythematous, desquamating eruption. Meanwhile thrush^ 

1 Mothers in England always describe the thrush as passing 
through the gastro-intestinal tract, and appearing on the skin 
around the anus as the erythematous rash. 



188 DESCEIPTION AND TREATMENT 

and mucous patches appear in the mouth, the child pines 
away, acquires a hoarse cry and dirty pallor, or caje-au-lait 
color of skin, and assumes a curiously stunted, wrinkled, 
ill- nourished, senile aspect. The liver and spleen may 
occasionally be felt to be enlarged, diffuse stomatitis and 
sw^elling of the gums without ulceration cause the early 
decay of the milk-teeth, and the characteristic malforma- 
tion of the permanent set. Condylomata appear a few 
weeks after the onset about the anus and mouth especially, 
and in the latter situation, when they ulcerate, leave shiny 
cicatrices, which are of great diagnostic importance in 
after-life. About the fifth month the eye affections are 
not very uncommon — e. g., usually symmetrical iritis, and 
inflammation of the vitreous, choroid, and retina. If the 
child survives, relapses of the eruptions may occur for a 
considerable time, with diminishing copiousness and extent 
of distribution. These symptoms correspond with the 
secondary stage of acquired syphilis, and extend over a 
year or eighteen months, as a rule ; after two years of age 
these eruptions are very rare. 

In contrast with acquired syphilis, various characteristic 
lesions of bone may occur — viz., thinning of the cranial 
bones in spots and patches (craniotabes), osteophytic 
thickenings or bossings about the anterior fontanelle, and 
swellings about the junction of the epi- and diaphyses of 
the long bones, etc. As the child grows up, the traces of 
past disease are seen in the stunted growth, the dirty 
anaemic skin, the collapsed bridge of the nose, the high 
broad forehead, the decayed milk-teeth, or divergent, 
pegged, notched, central upper permanent incisors. The 
symptoms corresponding to the tertiary stage of acquired 
syphilis, though they may be present in utero or infancy, 
usually occur after the fifth year (Hutchinson), or about 
the second dentition, or puberty. Tertiary skin-lesions 
have been recorded up to twenty or later. A curious form 



OF SKIN DISEASES. 189 

of deafness coming on about puberty, and interstitial kera- 
titis, kerato-iritis, etc., are also observed. 

The Erythematous Macular syphilide rarely 
bears any close resemblance to the roseolous eruption of 
acquired syphilis, either in aspect or site. It especially 
affects the upper part of the back of the thighs, nates, and 
genitalia, and thence may spread over the whole body. 
These ill-defined, coppery macules may run into large 
patches, and are often associated with diffuse desquamative 
conditions of the palms and soles. The papular syphilides 
are often developed about similar regions by the gradual 
infiltration of the neoplasm into the macules, and in other 
cases they correspond more closely with the characters seen 
in acquired syphilis. The circinate appearance is rarely 
seen. Condylomata, as might be expected, are of frequent 
occurrence about the mouth, nose, anus, toes, and moist 
folds of skin. Erosion and crusting and the formation of 
little pinched-out ulcers is common. Pustular syphilides of 
all sizes are frequent, and a multiform eruption of macules, 
papules, and small pustules must not be confounded with 
eczema, or especially scabies. Rupial crusts are very rare. 
The true bullous syphilide (pemphigus) is far more frequent 
than in the acquired disease and may occur as early as the 
sixth or seventh month of intrauterine life, and so is often 
present at birth or a few days after. It is the most pre- 
cocious syphilide of hereditary syphilis, and may occur as 
late as the eighteenth day, or perhaps later. The bullae 
range in size from the varicella eruption upwards, and are 
surrounded by a livid areola. They are characteristically 
developed about the hands and feet, especially the palms 
and soles. The tubercular syphilide is very rare, but, it is 
said, may be met with from the sixth month till just after 
puberty. It must be diagnosed from lupus and scrofulo- 
derma. The gummata do not differ materially from those 



190 DESCRIPTION AND TREATMENT 

seen in acquired syphilis, but a rare form simulating furun- 
cles may be mentioned (^Phlegmonous syphilides). 

Treatment. — We possess in mercury and the iodides of 
potassium and sodium constitutional remedies of undoubted 
efficacy in the treatment of syphilis. Mercury is the 
curative agent we employ in the primary and secondary 
stages, and its influence grows less effective as the late 
secondary, and especially the tertiary, symptoms appear ; 
and it is then that iodide of potassium comes into play, for 
it is useless in early syphilis. It should be borne in mind 
that syphilis is a most depressing and anaemia-producing 
disease, and, therefore, the system should be supported 
steadily by tonics and cod-liver oil, fresh air and exercise, 
plain and nourishing diet, and excess of alcohol should 
particularly be avoided. The exhibition of mercury should 
be continued, with some intermissions, for at least a year. 
The tonic effects are required, and salivation is not needed. 
It is useless to destroy the initial lesion, which may be 
dressed wdth some simple lotion, as black or red w^ash, lead 
lotion, or, if there is suppuration, iodoform. Mercury 
may be exhibited by the mouth in pills, powders, or mixt- 
ures; through the skin by fumigation or inunction ; hypo- 
dermatically, or per rectum by suppositories. The method 
of exhibition chosen must depend on many circumstances, 
such as the health of the patient, his idiosyncrasy with 
regard to mercury, his means, etc. Gray powder, blue pill, 
and the bicyanide and protoiodide of mercury are amongst 
the best preparations by the mouth (F. 134, 133, 132, 131), 
and to these, opium, henbane, or conium may be added if 
the bowels are much irritated. The bichloride of mercury 
(F. 124-6) is useful in later stages. Inunction is effected 
by rubbing into the skin each night a scruple of blue oint- 
ment, taking care to vary the non-hairy site each time, and 
oleate of mercury (F. 51) has also been substituted. In 
infantile syphilis, a cloth may be kept saturated with the 



OF SKIN DISEASES. 191 

ointment and bound round the waist by oil silk, but the 
gray powder (gr. j-ij bis die) is very convenient for children. 
Calomel fumigation (F. 2) is preferred by some as not de- 
ranging the stomach, and salivation is rarely produced by 
it; and it has this advantage, that the skin affections, where 
extensive, are simultaneously attacked locally. It is de- 
bilitating, however, and catching cold must be avoided. 
The subcutaneous injection of mercury is a rapid method 
for some cases, but is not much used in this country. Iodide 
of potassium may be combined wath mercury (F. 127, 128, 
130), where it is possible the syphilis is still amenable to 
both drugs, and in late syphilis the iodide of potassium 
may be conveniently dissolved in the syrup of the iodide of 
iron (F. 136, 137). Some persons are extremely susceptible 
to iodine, and rapidly get iodized, w^hilst others bear grs. 
v-x-xv of the potassium salt t d. s. well. AVhere the health 
is greatly broken, a sojourn at the seaside or a sea voyage 
is advisable. A very thorough treatment by the inunction 
of mercury and the administration of sulphur waters is 
carried out at certain spas. Locally, extensive, non-ulcer- 
ating eruptions may be dusted with powders or simply 
hidden by calamine lotion (F. 83) mixed with black wash, 
or eruptions limited in distribution may be treated by mer- 
curial salves (F. 50 et seq.). Where ulceration exists, the 
crusts must be removed by poulticing, and the surface 
dressed with iodoform applications (F. 37), the iodide of 
starch paste (F. 36), mercurial plaster (F. 88, 89), local 
mercurial fumigation (F. 2), or simple healing dressings 
(F. 52-54). Condylomata require strict cleanliness, sepa- 
ration of contiguous surfaces of the skin, and the applica- 
tion of a dusting powder of equal parts of calomel and 
either magnesia, oxide of zinc, or starch (F. 50). 

Tinea is the generic name given to diseases caused by a 
group of certain vegetable parasites, as the term phthiriasis 



192 DESCRIPTION AND TREATMENT 

is applied to the affections caused by lice. There are 
several different kinds of fungi which commonly flourish 
on the human body — viz., the Achorion Schonleinii, 
which produces Tinea favosa ^ or "favus" of the scalp, gen- 
eral surface, or nails ; the Trichophyton, which causes 
Tinea tonsurans^ or ordinary "ringworm'' of the scalp, Tinea 
circinata, or "ringworm" of the general surface, Tinea tri- 
chopkytina unguium^ or " ringworm " of the nails, the so- 
called Eczema marginatum, and Tinea sycosis, or " ringworm" 
of the hairy parts of the face ; the Microsporon furfur, 
which occasions Tinea or Pityriasis versicolor (formerly called 
chloasma). Lastly, Ohionyphe Carter! is supposed to 
be the cause of mycetoma, or " madura foot," or " the fungus 
foot of India." By many, one form at least of alopecia 
areata (tinea decalvansj is held to be brought about by a 
fungus, the microsporon Audouini. For ringw^orm and 
favus of the nails, see Onychomycosis. 

Tinea favosa is a very rare disease now-a-days in 
England, but is somewhat more common in the large cities 
of Ireland, and especially Scotland. It is occasionally 
met with in the United States. It is acquired by direct 
contagion, or by transmission from such animals as mice, 
rats, cats, canaries, etc. Favus is very rare in infants, but 
attacks particularly very poor, ill-fed, dirty children, and 
when seen in adults is generally of long standing. The 
favus fungus (^Achorion Schdnleinii) grows and flourishes 
between the upper and lower layers of the epidermis and 
in its appendages, and especially around the hair-follicles. 
The earliest signs are rarely observed, and the disease is 
generally well established when the patient is seen. If the 
surface has been cleansed for the occasion, it may look like 
a healing eczema, but in about three weeks a number of 
little, soft, millet-sized, straw^- or sulphur-yellow points (not 
pustules) are seen to form, each perforated by one or more 



OF SKIN DISEASES. 193 

hairs. These points grow to form raised, dry, friable, and 
laminated disks, the size of a threepenny piece, becoming 
depressed in the centre and elevated at the edges (the 
favus caps or godets faviques). Each disk is covered on 
either surface by epithelium, and when detached from its 
bed reforms. After long continuance, pressure causes 
atrophy of the skin and characteristic scarring. These 
yellow crusts may be discrete or confluent in large honey- 
comb-like masses, and then their individuality may be 
more or less retained or lost. The hairs are attacked, and 
rendered opaque, lustreless, and brittle, but not to the same 
extent as in ordinary ringworm. Favus most frequently 
attacks the hairy scalp, but may be found on the extremi- 
ties, trunk, and elsewhere. It can hardly, when well de- 
veloped, be mistaken for any other disease, and there is a 
peculiar smell emanating from the patches, comparable to 
the odor of mice or a cat's urine. Each favus crust consists 
of a granular matrix, now known to be formed by the 
disintegration of epithelium and sebum, in ^hich a multi- 
tude of branched and unbranched mycelium tubes course 
towards the centre of the crust, to terminate in moniliform 
strings and masses of rounded or oval spores, rather larger 
on the average than those of the trichophyton. 

Treatment. — The soil must be rendered less suitable 
for the growth of the fungus by administering good food, 
fresh air, cod-liver oil, blood tonics, etc. The eradication 
of the fungus present, especially on the scalp, presents 
great difficulties. The scalp must be thoroughly cleansed 
by keeping the hair shaved or cut short, by soaking the 
crusts in oil poultices, or by water packing, and by washing. 
For a choice of parasiticide remedies, we refer the reader 
to the treatment of chronic tinea tonsurans, and will only 
add that, after a cure is apparently effected, the case must 
be carefully watched for some months. 

17 



194 DESCEIPTION AND TREATMENT 

Tinea trichophytina, or '' ringwofm/' is a term 
applied to designate the various forms of mischief occa- 
sioned in the skin and its appendages by the growth there 
of the Trichophyton tonsurans (Malmsten), and it embraces, 
as already explained, Tinea trichophytina circinata, or ring- 
worm of the general surface ; Tinea t tonsurans, or ringworm 
of the scalp ; Tinea t sycosis, or ringworm of the hairy parts 
of the face ; and Tinea t. unguium, or ringw^orm of the nails. 
These several forms may be met wath on the same person, 
or in the different members of a family, or one variety may 
give rise by contagion or extension to another phase. 

Tinea trichophytina, or ringworm, occurs in the rich as 
w^ell as in the poor, and is propagated almost entirely by 
contagion, either by immediate contact, or by using in- 
fected articles of the toilet, clothing, and so on ; but it is 
probable that the spores of the fungus are also disseminated 
through the air. It may also be contracted from cattle, 
horses, and domestic animals. At certain times it seems 
more prevalent than at others, and, when neglected, it 
occasionally runs riot in a village, or where children are 
congregated. The rapidity and the extent of its spread, 
and the length of its persistence, depend on the state of 
nutrition of the individual, some qualities of the fungus, 
and the amount of warmth and moisture present. Thus 
^' lymphatic," toneless children, or the pallid and ill-nour- 
ished, w^ho do not assimilate fats easily, are especially 
selected ; and it is notorious that where the members of a 
family are affected in one or more, and these the least 
robust, the disease is very intractable. Then, again, tinea 
circinata flourishes with great luxuriance in the tropics, 
and the fungus contracted from animals excites much in- 
flammation. Tinea tonsurans especially attacks children, 
from late infancy up to thirteen or fourteen years of age, 
and but rarely adults, though the latter more frequently 
contract tinea circinata. The fungus growls especially 



OF SKIN DISEASES. VJh 

between the lowest layers of the cuticle and the upper rete 
layers, and in chronic eczema marginatum, and in tropical 
ringworm, penetrates still deeper into the rete. Where 
hairs exist, and particularly on the scalp, the fungus grows 
down between the hair and the follicular wall ; and, in- 
sinuating itself beneath the cuticle of the hair, ramifies 
up and down between the fibres. There it splits up and 
separates the fibres, and causes the brittleness, opacity, and 
distortion to be described. There is at present some uncer- 
tainty whether the growth of the fungus is limited to effete 
epidermic structures, or whether it may spread to the root 
sheaths, papillae, and corium, for instance. It is absolutely 
necessary to be thoroughly acquainted with the character 
of the diseased hairs and skilled in the detection of thi^ 
fungus,^ which consists of wavy, smooth-margined, trans- 
parent mycelial tubes or threads, generally unbranched, 
jointed or unjointed, and generally in the hair, terminating 
in moniliform chains or rounded or oval transparent spores 
or cells, about half the diameter of a red blood-corpuscle. 
In T. circinata we see principally a network of simple and 
beaded mycelium in the upper layers of the skin, whilst in 
hairs spores predominate. 

Tinea circinata usually begins as a little reddened, 
faintly raised, itchy, erythematous macule, which tends to 
enlarge by a well-defined raised border, and to clear in the 
centre, leaving only some pigmentation and desquamation. 

^ To demonstrate successfully the fungus in the skin, the deeper 
cuticular and upper rete cells should be scraped or cut from the 
spreading edge of T. circinata, or in a hair it should be carefully 
pulled out from the centre of a patch of T. tonsurans. The speci- 
men should then be soaked for a short time in weak liquor potassse, 
and spread out by the covering glass for microscopical examina- 
tion. Fatt}^ granules and globules, which may easily be mistaken 
for spores by the inexperienced, can be got rid of by first soaking 
the hair in ether. 



196 DESCRIPTION AND TREATMENT 

The fungus grows amongst the epidermic structures, and 
excites more or less inflammation, according to the suscep- 
tibilities of the patient, and the irritating quality of the 
fungus. If the inflammation be slight, only an erythema- 
tous patch results; if more severe, sufficient eff'usion of 
serum may take place to form papules or vesicles, usually 
situated on the extending edge, and thus, in years gone by, 
the terms lichen and herpes circinatus came to be applied. 
The rings may attain to the size of a half-crown or five- 
shilling piece, or in the tropics to six inches diameter, and 
then seem to die away or remain as a chronic patch. There 
may be only one patch present, or a great number, and in 
the tropics, where the ringworm fungus flourishes with 
great luxuriance, a large area of the body may be pat- 
terned and festooned with confluent rings. In England, 
tinea circinata is a trivial though frequent aflfection, occur- 
ring mostly in children, and especially about the neck, face, 
and hands, and tending to disappear spontaneously. Sev- 
eral special phases must, however, be further noted. One 
form already referred to, and so common in the tropics, is 
variously described as Chinese, Indian, Burmese ringworm, 
and Dhobies' itch. It is ordinary ringworm, which assumes 
exaggerated characters from rapid and luxuriant and ex- 
tensive growth. It is very common about the fork of the 
thighs, and occasionally intractable cases are seen in those 
w^ho return to England from w^arm climates, and then 
shows as a chronic, itchy, recurrent, erythematous, papular, 
or desquamating eruption. So-called eczema marginatum 
is now recognized to be a chronic ringworm, which induces 
a condition closely simulating a patch of chronic eczema. 
It is usually met w^ith about the inner and upper part of 
the thighs and neighboring parts, and also in the axillae, 
and beneath hanging folds of skin. It commences as a 
red, itchy, scurfy spot, and on the thigh spreads by a raised 
border, often studded with papules, and, it is said, vesicles. 



OF SKIN DISEASES. 197 

and assumes a circular outline. It gets excoriated and in- 
filtrated, and is often most intractable. It will be seen 
from this description that the diagnosis is sometimes at- 
tended with difliculty, and, indeed, can only be made with 
certainty after a careful examination for the fungus. As 
a broad rule, we may say that all itchy circinate patches 
should excite the suspicion of ringworm, especially if local- 
ized and single; but it should be borne in mind, first, 
that the circinate character is one common to many skin 
diseases — e. g., old psoriasis, lupus erythematosus, relapsing 
and late syphilides, mucular leprosy, and many erythe- 
raata {see these diseases) ; and, secondly, that the circinate 
character is not present in the earlier stages, and tends to 
be lost in very chronic patches, and then comes to resemble 
old areas of eczema or artificial dermatitis, or psoriasis. 

Tinea tonsurans, or "ringworm" of the scalp, seems 
to be far more common in Europe than in America, and is 
a never-failing source of annoyance to all concerned. Its 
usual beginning on the scalp is by one or more itchy, des- 
quamating, or scurfy, more or less circular, and often red- 
dened spots. The circinate aspect is sometimes presented, 
especially in infants, but is not a common feature, at any 
rate when the disease is well established. As the fungus 
grows in the cuticle and the patches enlarge, the hairs also 
become implicated and rendered brittle, and break ofi", 
causing a remarkable and characteristic " bald patch," which 
attracts the attention of the patient's friends, because it 
stands out in remarkable contrast to the surrounding hairy 
scalp. The fungus often spreads primarily from several 
centres, or at any rate soon becomes inoculated about the 
scalp by scratching, etc., and the various patches, varying 
from a half to several inches in diameter, tend to join and 
so affect extensive surfaces. These " bald patches " are 
usually of a grayish color, from the covering of fine scurf, 

17^ 



198 DESCRIPTION AND TREATMENT 

consisting of epidermic scales, sebum, and fungus, masking 
any congestion of the underlying tissues set up by the 
growth of the parasite. Over the diseased surface, the 
hairs might convey the impression of having been nibbled 
off close to the scalp, for they are stunted, swollen near the 
skin, opaque, and lustreless, often t^yisted and bent, loosened 
in the erected follicles, excessively brittle, and frequently 
surrounded by little whitish, asbestos-like sheaths, w^hich 
they carry up on their shafts as they emerge from the 
follicle. There are a good many variations in appearance 
from this typical ringw^orm of the scalp, none of which, 
however, should pass unrecognized if the characters of the 
diseased hairs and the fungus be fully apprehended. Thus 
the diseased hairs may not be so very conspicuous on super- 
ficial examination, either from being mixed up with a large 
proportion of healthy hairs, or from being as yet unbroken 
(though brittle), and only lustreless, opaque, irregularly 
grown, and dwarfed. Then the degree of inflammation set 
up by the growth of the fungus varies a good deal, and 
the desquamation and congestion may be slight, or more 
or less pustular dermatitis may supervene to mask the 
hairs, either in discrete spots or over the whole patch, or 
seborrhoea may be excited and then the fatty plates cake 
dow^n and conceal the hairs. Sometimes, by reason of the 
special susceptibility of the soil, or the irritating character 
of the fungus, a patch wdll spontaneously become swollen, 
boggy, tender, livid like a threatening abscess, and studded 
with the dilated mouths of inflamed follicles which exude 
a viscid serous fluid, a condition known as Tinea Jcerion, 
and not to be confounded wath pustular ringworm. Lastly, 
too much stress must not be laid on the circular, much less 
the circinate, character of the patches, because not only 
does their coalescence destroy this, but the circular outline 
of individual patches is lost after a time. 



OF SKIN DISEASES. 199 

Tinea sycosis is the term applied to riDgworm of the 
hairy parts of the face, which is far more common in 
France and some other countries than in England and 
America, and the name sycosis has been borrowed because 
that quite distinct affection is closely simulated. In ap- 
pearance it differs widely, according to the amount of in- 
flammation excited ; thus, it may resemble a tinea circinata, 
or the presence of acneiform papules and pustules may 
cause it to closely resemble ordinary sycosis, or the inflam- 
mation may be more intense, especially when contracted 
from cattle and horses, and large pustules, free crusting, 
general swelling, boils, nodules, and abscesses may form. 
It is often asymmetrical and very intractable. The hairs 
become affected exactly as in tinea tonsurans. 

Tinea trichophytina unguium (see with Tinea 
favosa unguium under Onychomycosis^. 

Treatment. — The points to be kept in mind are (1) to 
influence the soil so as to render it in the least degree favor- 
able to the fungus ; (2) to destroy the parasite ; (3) to 
remedy the consequences (baldness, inflammation) of the 
presence of the parasite, and of the destructive treatment 
employed. The first point is effected by subjecting the 
children to good hygienic conditions, and fresh or sea-side 
air, by regulating the food in proper proportions, and espe- 
cially the fatty element, and by administering ferruginous 
preparations, cod-liver oil, etc. A great number of sub- 
stances are parasiticidal, and the choice of one must be 
determined by the site of the disease, w^iether on the body 
or in the hairy scalp or beard, by its extent and duration, 
the age and susceptibilities of the patient, and so on. As 
the fungus in T. circinata does not extend, as a rule, below 
the uppermost rete layers, it is easily removed by the ap- 
plication of a blistering substance, or by setting up inflam- 
mation, and causing crusting or repeated free desquamation, 



200 DESCRIPTION AND TREATMENT 

and this may be effected by painting on the part one or 
more times either blistering fluid, strong acetic acid (not 
glacial), or solution of nitrate of silver (3j to 5j), or tinct. 
or liniment of iodine, or perchloride of iron. Any crusts 
may be bathed off, and the raw surface dressed with a 
soothing salve. The disease is, however, easily cured by 
rubbing well in, twice daily, any of the following less irri- 
tating salves, viz., ung. zinci sulphatis 5j to 3j (in infants), 
ung. hydrarg. ammoniati (one-quarter to one-half the 
strength of the Brit. Pharra.), ung. hydrarg. nitratis (5j of 
ung. nit. to 3vij vaseline), ung. acidi carbolici (5j to 3j), 
ung. picis liquid., or Wilkinson's salve F. 106). Thymol 
and salicylic ointments (F. 80, 64) are eflTective, unirritat- 
ing, and cleanly. Precipitated sulphur is one of the best 
applications (hydrargyri ammoniat., Bij, ung. sulph. ad 3j). 
Very chronic patches of T. circinata and eczema margin- 
atum may prove obstinate, and require strong remedies 
thoroughly well rubbed in (F. 112, 122, 118, 33). 

With regard to T. tonsurans it is necessary to remark 
that if the disease be extensive, the hair over the whole 
head should be kept cut short (save only a fringe) ; or if 
only one or two patches exist, the hair around them only 
should be removed. It must be borne in mind also that 
ringworm is contagious and gets inoculated about the scalp 
and general surface, so that a constant watch must be kept 
up for fresh places, and care be taken that the disease be 
not propagated from one to another by the interchange of 
caps, brushes and combs, towels, comforters, linen, etc. 
Further, it is well for the patient to wear a simple linen or 
other cap, constantly, which may be easily disinfected or 
destroyed, from time to time, both for the purpose of isolat- 
ing the scalp and preventing the removal of the applica- 
tions to the eyes, etc. 

The difficulty in curing T. tonsurans will be according to 
the power of growth of the fungus, and the time it has 



OF SKIN DISEASES. 201 

been at work. If the disease be very recent, any of the 
above-mentioned applications will suffice, as with T. cir- 
cinata; but, if the fungus has spread down the follicles 
and into the hair nearly to the bulb, weeks and months of 
unceasing application of parasiticides will be necessary. 
If the disease be extensive and diffuse, rags soaked in a re- 
cently made saturated solution of sulphurous acid (F. 123) 
may be constantly applied under oil-skin caps, or carbolic 
glycerine (1 part of carbolic acid to 1 to 5 parts of gly- 
cerine) is a fairly good remedy, rubbed in several times a 
day. Oleate of mercury (F. 51), and F. 113, 122, 118, 
119, 120, are amongst the very best of applications, and 
produce no ill results. The great point is to rub in the 
remedy selected as thoroughly and as frequently as possible, 
short of producing much inflammation. 

When from the first, or in the course of time, we have 
to deal with chronic localized patches, we may resort to set- 
ting up pustular inflammation around the hairs, as the pus 
is inimical to the fungus, and loosens the hairs. With this 
view Coster's paste (F. 116), or lin. crotonis (B. Ph.), or 
F. 115, may be painted on, and the resultant crusts allowed 
to fall, or be torn forcibly off. The latter process introduces 
us to an additional help in epilation, or the extraction of 
diseased hairs, with suitable forceps — a tedious operation, 
which is of the greatest value, when the loosening of the 
hairs by irritant applications allows them to be gently 
dragged from the follicles with the shafts imbroken. Epila- 
tion is of especial value in favus and tinea sycosis. If the 
patch be rather too extensive to excite pustular inflamma- 
tion for fear of the subsequent scarring, frequent paintings 
should be made with the lin. iodi or pigmentum iodi (twice 
the strength of tincture), or rubbing with Goa powder, the 
scalp having been previously wetted with dilute acetic acid. 
These methods of treatment may be advantageously alter- 
nated with one another. 



202 DESCRIPTION AND TREATMENT 

For intractable patches not more extensive than half-a-crown, 
a further treatment has been introduced in the last few 
years, founded on the fact that in cases where kerion spon- 
taneously arises, the disease rapidly cures itself by the fall 
of all the diseased hairs. This treatment then is to excite 
kerion (see the description of this condition) by daily ap- 
plication of croton oil, or, better, equal parts of croton oil 
and lin. crotonis, with persistent poulticing in between 
these paintings. The hairs may then be removed, and the 
boggy swelling rapidly subsides by constant bathing and 
soothing remedies. It only remains to say that it is ab- 
solutely essential to be thoroughly acquainted with the 
characters of ringworm stumps and the fungus to be able 
to distinguish them when sparsely disseminated about the 
scalp amongst healthy hairs, or when masked by seborrhoea, 
or pustular eczema, otherwise the most elaborate explana- 
tions will fail to bring out a correct diagnosis or knowledge 
as to when an old-standing case is cured. 

Tinea versicolor (Pityriasis versicolor vel Chloasma) 
is characterized by the formation of more or less circular, 
fawn or liver-colored disks (dark brown occasionally), 
situated mostly about the hair-follicles, and due to the 
growth in the cuticle of the microsporon furfur fungus. 
They are, as a rule, very faintly elevated, frequently 
smooth and glistening, though the nail will readily disen- 
gage scales, and occasion so little discoloration or dis- 
figurement that they are sometimes not very apparent, 
except in certain lights. The degree of discoloration varies 
very much, and there may be a pink hue present from 
hypersemia. The disks spread peripherally and very slowly 
to coalesce into extensive, irregular areas, enclosing islands 
of normal skin, and eventually the characteristic circular 
spots are only traceable on the borders. It most commonly 
affects the warm moist epigastrium and sternal regions, 



OF SKIN DISEASES. 203 

between the shoulders, and in course of time, if left undis- 
turbed and the soil be favorable, it may extend on to the 
neck, round and down the trunk, and reach the thighs and 
upper part of the arms. It is essentially a disease of adults 
from twenty to fifty years of age, and its growth is favored 
by warm clothing and moist conditions of skin, and hence 
is more common in the delicate, especially the phthisical. 
Its spread is very chronic and insidious, and it is slightly 
contagious. It must be carefully distinguished from pig- 
mentary stains (true chloasma) and a fading roseolous 
syphilide. 

Treatment. — Most parasiticides will eflTect a cure, but 
they must be long persevered w^ith or the disease will 
return. Ointments are most effectual for hospital practice, 
but in private practice it is well to thoroughly cleanse 
away all sebum and loose epithelium, by thoroughly washing 
with soap and hot w^ater, and then to apply F. 67, 111, 58. 

Teleangeiectasis is the name applied to little capillary 
dilatations and new formations in the skin, either arising 
idiopathically or in connection with diseased states of the 
skin ; for instance, about the face in acne rosacea and about 
patches of morphcea. It is also applied in a rather differ- 
ent sense to the forms of capillary anginoma which spread, 
in distinction to the non-spreading nsevus vascularis. (^See 
Nsevus.) 

Ulcus Orientalis, or Oriental Sore, is a term which 
may be conveniently applied to embrace a number of boil- 
like inflammations or ulcers, bearing a close resemblance 
to one another, which are met with in tropical or sub- 
tropical regions, and variously known as Boutons de 
Biskara (Algeria), de Bagdad, d'Aleppo; Delhi, Mooltan, 
Lucknow, and Kandahar "sores;" Scinde and Lahore 
boils; Caneotica (Crete), etc. 



204 DESCRIPTION AND TREATMENT 

There are many other ulcers kno\Yn as Cochin China, 
Mozambique, and Natal sores, or ulcers, the exact nature 
of which is hardly clear, nor is their relation to yaws defi- 
nitely settled. It has been established that under these 
terms a heterogeneous mass of affections has been included 
of a lupoid, syphilitic, malignant, and scrofulous nature. 
Moreover, people debilitated and cachectic under climatic 
conditions, mal-hygiene, and bad food, are extremely subject 
to furunculus and to ulceration following any wound or 
abrasion, But it nevertheless seems clear that there is a 
specific affection meriting a distinct description, and 
English troops in India have in times past been scourged by 
it. The affection commences by localized itching, and the 
formation of a firm pink papule, not unlike a mosquito- 
bite, and the hair and gland sacs seem to be specially 
involved. This papule, or nodule, as it enlarges gets 
more vascular and softer from effusion, and first of all 
desquamates, and then a scab forms (one to two months), 
under which ulceration goes on. The ulcer commonly 
reaches the size of a shilling, or half-a-crown, but there is 
much variation in the intensity of the ulceration. The 
ulcer is very chronic and often intractable, and lasts from 
four to eighteen months, or longer, but it is not dangerous. 
It gradually cicatrizes in the centre, and in healing leaves 
an indelible scar. There may be a dozen or more of these 
sores on the same person, and one may be surrounded by 
several others, and several may coalesce. It seems to occur 
only once in a lifetime. The commoner sites are the back 
of the elbow, forearms, backs of the hands and fingers, the 
ankles, face, legs, thighs. Unexposed parts are rarely 
attacked. It attacks all races, natives and Europeans, 
both sexes, and occurs at all ages. New-comers to a district 
are especially prone to take the disease, and in India it 
is confined to cities. The cause is not clear at present, but 
the sores are dependent probably on the peculiar chemical 



OF SKIN DISEASES. 205 

character of the water. Some think it has a parasitic 
causatioil. 

Treatment. — The most approved treatment seems to be 
to burn the sore out at an early stage if possible, for the 
ordinary local measures for the treatment of ulcers is futile. 
A thorough building up of the health is required in many 
cases ; at least in cases coming to Europe this plan is most 
successful. 

Urticaria, or Nettlerash, is characterized by the 
formation in the skin of circumscribed, soft, more or less 
rounded elevations known as Pomphi or Wheals, w^hich 
have several remarkable characteristics, and which are well 
illustrated by the effects of the stinging nettle. These 
wdieals are due to an acute oedema, very rarely copious 
enough to cause a bulla, implicating circumscribed areas, 
varying in size from a split pea or finger-nail to the palm 
of the hand, and are pink or a delicate red iu color, with 
the central portion often blanched, when the oedema is 
sufficient to mask the greater part of the underlying hyper- 
semic redness. These wheals are of rapid formation and as 
characteristically evanescent, and they are intensely itchy 
and stinging. Though usually of rounded or oval outline, 
w^heals may assume an annular character (see Roseola 
urticata), and then coalesce to form gyrate patterns on the 
skin. Their appearance is also altered by the depth to 
w^hich the oedema extends in the skin, for they may form 
simple erythematous blotches or more rarely large pink 
subcutaneous swellings, and when in the loose connective 
tissue of the eyelids, lips, or pharynx they cause much 
distress. 

Wheals are usually described as inflammatory, and urti- 
caria is classified with the erythemata. The immediate 
cause of the little areas of acute oedema seems to be a 
temporary paresis of vaso-motor nerve twigs, and this 

18 



206 DESCRIPTION AND TREATMENT 

paresis is brought about either by external influences operat- 
ing on the skin, such as bites by bugs, lice, and fleas, the 
burrowing of the itch insect, the crawling of caterpillars, 
scratching (factitious urticaria), sea water, cold air, etc. ; 
or, secondly, by influences radiated from within the body, such 
as the gastro-intestinal tract, the uterus, etc. ; and, thirdly, 
probably by an impure blood current. There is no doubt 
that in urticaria there is a strong underlying neurotic ele- 
ment or unstable condition of the nervous system which 
must always be taken into consideration. Beyond this no 
definite cause can be made out in some cases, but the 
majority of patients are dyspeptic, debilitated, and out of 
sorts. 

Urticaria may be marked by the presence of only a few 
wheals, or the whole body may be covered. They may 
occur in an acute outburst accompanied by febrile disturb- 
ance, and considerable general trouble and prostration, and 
then are generally due to the ingestion of unwholesome 
food, such as particular kinds of fish (e. g., mussels), tinned 
meat, etc., or articles of diet, such as strawberries, against 
which there exists a peculiar idiosyncrasy. Chronic urticaria 
is generally excited by some derangement of the alimentary 
tract, but in some cases it is traceable to uterine disorder, 
and it may occur in pregnancy. Some very chronic cases 
are seen in neurotic subjects, and periodical outbursts 
of wheals may occur. 

Lastly, urticaria presents some difference in the adult 
and in the child, for in the former the wheals are almost 
always fugitive, and rarely leave pigmentation behind, 
whereas in infants it is somewhat more common, but still 
rare, for the wheals to be comparatively persistent and 
leave tawny stains, which quite mislead the uninitiated 
{U. pigmentosa). Again, in children, there is a common 
and troublesome form of chronic urticaria {TJ. papulosa), 
not due to insect bites, but commonly to chronic intestinal 



OF SKIN DISEASES. 207 

or gastric disturbance, and long known as lichen urticatus^ 
on account of the tendency there is in children for papules, 
due to little depositions of lymph, to be left behind by the 
fugitive wheal. It must be carefully distinguished from 
insect bites and scabies, as in cachectic children a multiform 
eruption is brought about by scratching, pus formation, etc. 
Treatment must depend on the exciting cause, into 
which careful inquiry should be made. Thus, if due to 
some external agency, such as bugs, this must be removed. 
The acute form in the adult, due to the ingestion of 
particular kinds of diet, should be treated by an early 
emetic, and subsequently a sedative mixture of bismuth 
and hydrocyanic acid. In chronic urticaria of the adult, if 
not due to such a well-marked cause as pregnancy or ague, 
great care should be taken to try and find out any stomach, 
uterine, or liver derangement, or loss of nervous tone due 
to overwork, anxiety, etc. The dyspepsia may require an 
antacid, a mineral acid, or sedative, or some aid to diges- 
tion as pepsin ; the nervous system may require a tonic or 
bromide of potassium, and so on. Dover's powder is often 
very effective in chronic cases. Arsenic and quinine are 
useful in periodic cases, and generally it may be laid down 
that, first, any obvious derangement of the health, as 
dyspepsia, should be set right and then the nervous system 
be toned up. In children, gastro-intestinal derangement is 
almost invariably the exciting cause, and the feeding must 
be carefully supervised. Locally, Ave may give relief by 
an evaporating or cooling lotion (F. 44, 15), or ointment 
(14), or astringent (F. 79, 13), or soothing application (F. 
20-22, 65, 66, 83), or slight stimulant (F. 16, 19, 31, 57, 
76, 77), or sedative (26). The tinct. saponis viridis et picis 
(F. 74), diluted with five parts of water, makes an effective 
lotion in lichen urticatus. Alkaline, or starch, or sulphuret 
of potassium baths (F. 1) are often very grateful. 



208 DESCRIPTION^ AND TREATMENT 

Vaccinal Eruptions, or lesions of the skin depen- 
dent on the operation of vaccination, may be thus classified : 
(A) Unhealthy conditions of the pustules or wounds, which 
may consist in more or less diffuse erythema, erysipelas, 
ulceration, and rarely gangrene, and arising from want of 
cleanliness and proper protection of the part, the intensity 
of the local inflammation, or cachexia. (B) The inocula- 
tion of syphilis by the admixture of blood with the vaccine 
matter. In such a case the vaccine pustules do not run a 
typical course, but when they ought to be healed over, the 
sore, or region, begins to indurate. Possibly leprosy and 
yaws may be also inoculated thus. (C) General eruptions 
excited by the disturbance of the system. Thus, a roseola 
vaccinia, to be distinguished from measles and scarlatina, 
is not very uncommon, occurring about the time of matura- 
tion of the pustules. Similarly a general vesicular or 
pustular eruption is occasionally observed to be excited by 
the general disturbance, as in pysemia, but it is not a dis- 
seminated eruption of vaccine vesicles, and the disease 
cannot be inoculated from it (so-called vaccine generalisee). 
In cachectic children these pustules may become gan- 
grenous (vaccinia gangrcEuosa^. Lastly, eczema, and pso- 
riasis, and urticaria, may also be excited in those so 
predisposed, just as vaccination, by its alterative effects, 
will sometimes remove chronic eruptions. 

Verrucse, or Warts, are circumscribed hypertrophies 
of groups of papillse associated with some overgrowth of 
immediately subjacent connective tissue, and more or less 
overproduction of epidermis. They range very commonly 
about the size of a split pea, and may be sessile or pedun- 
culate. Only a few may exist, or they may appear in 
great numbers. They occur in both sexes, more especially 
in the young. As for the cause, it is often obscure ; but 
certain ill-conditioned subjects seem to have a tendency 



OF SKIN DISEASES. 209 

to them, whilst in others acrid discharges, or other irrita- 
tion, seem to excite them. They vary somewhat in size 
and detail of appearance, according to their site, for on 
the hands they may be smooth or not much divided up, on 
the backs of old people flat and broad, on the face long 
and thread-like, and on the scalp spread out and digitate. 
Again, about the genitalia, and more rarely in other moist 
situations, warts are excited by irritating discharges, and 
often grow rapidly and luxuriously, and coalesce to form 
large offensive secreting masses. These vascular growths 
are known as venereal ivartSj pointed condylomata, or verruca 
acuminata, to distinguish them from the syphilitic con- 
dylomata (see syphilitic papules), and from " vegetating 
syphilides." 

Treatment. — Common warts may be destroyed by re- 
peated applications of glacial acetic acid, or chromic acid 
(F. 11), or by the stronger caustic potash (1 part to 3 of 
water), or acid nitrate of mercury (F. 9), taking care to 
protect the surrounding skin. If the tendency to their 
development is marked, arsenic is recommended, but all 
irritating secretions must be looked to. Non-syphilitic 
venereal warts should be kept scrupulously clean, and 
dusted W'ith calomel or some disinfectant astringent powder 
(F. 90 et seq.). If not relieved, they may be snipped off 
with scissors, or, if very vascular, ligatured, or removed by 
the galvano-caustic wire, and the bases touched wdth nitrate 
of silver. 

Xanthelasma, or Vitiligoidea, is a disease charac- 
terized by the formation of either sharply defined, slightly 
raised, smooth, soft patches or streaks of a lemon, cream, 
or buff-yellow color like chamois leather imbedded in the 
skin (X, planum), or of "tubercles," or nodules of various 
sizes from a pin-head to a walnut (X. papulatum et tube- 
rosum). The larger patches are formed by the aggregation 

18* 



210 DESCRIPTION AND TREATMENT 

and fusion of the smaller papules, and, when formed, either 
remain stationary or increase, but rarely disappear, and 
show no tendency to inflame. Clinically there are two 
main sets of conditions under which this affection occurs, 
as follows : X. palpebrarum is a fairly common affection, 
not in the young, but of the middle and senile periods of 
life, in women mostly, and begins almost invariably about 
the inner canthus, and especially the left, as little discrete 
papules, which later generally become aggregated into flat 
patches to form a crescent. Next the outer canthus is 
similarly and independently affected, and finally the upper 
lid and then the lower lid may be almost entirely encircled, 
and usually on both sides. Some sebaceous glands may be 
prominently involved and plugged in the patches, and 
occasionally cysts form. Mr. Hutchinson, from an analysis 
of seventy-four cases, concluded that people suffering from 
X. palpebrarum have been especially prone to sick head- 
aches, bilious attacks, and other evidences of functional 
disturbance of the liver (not jaundice), and that the patches 
are predisposed to by any cause capable of producing dark 
areolae round the eyes (? pigmentation or venous conges- 
tion) — e. g., pregnancy, ovarian disorder, liver derangement, 
or mere nervous fatigue. He also relates two cases in this 
category preceded by jaundice and enormous enlargement 
of the liver, which subsequently subsided. This form may 
exist in several members of a family and in successive 
generations. 

In X. multiplex or xanthelasma of the general surface y of 
which about twenty-five cases are on record, though it is of 
somewhat more frequent occurrence than this statement 
suggests, the papules, streaks, and patches usually first 
form in the eyelids, though the latter may remain un- 
affected, and later in the natural folds and creases of the 
palms, and then those of the face, neck, ears, scrotum, 
soles of the feet, flexures of the abdomen, the cleft of the 



OF SKIN DISEASES. 211 

nates, and the back. In very chronic cases — and the 
progress of the affection is very slow — projecting tubercles, 
nodules, or phymata may form. Maculae have also been 
found in the mucous membrane of the mouth, lips, tongue, 
palate, trachea, bile-ducts, etc. This general form has 
almost invariably been preceded by long-continued, often 
recurrent, jaundice, arising from an organic cause — viz., 
simple and cancerous stricture of ducts, cirrhosis, occlusion 
by gall-stones and hydatids, and chronic liver atrophy ; 
and rarely by diabetes. The ages varied from twenty- 
eight to fifty-eight, though one case was only sixteen. 
Several remarkable cases, how^ever, are on record in which 
the affection was not associated wdth jaundice, and began 
in infancy; but though, in the case of tw^o brothers (Startin, 
Stephen Mackenzie) there w^as little clue to the cause, in 
the others (Colcott Fox) there W'Cre remarkable bone 
changes of a gouty or rheumatic nature. There is some 
difference of opinion as to the exact nature of the changes. 
The corium, however, is at first the seat of a chronic in- 
flammatory exudation of leucocytes, or of a new growth 
rich in young cells, and the latter become distended with a 
yellow oil, either as the result of a degenerative process, or 
as a true deposit, for it appears that the cell elements 
themselves persist. In the tuberose eruption the cells and 
intercellular matrix become organized into a new growth 
of connective tissue. 

Treatment. — When once formed, the patches persist, 
and there is no known method of getting rid of them by 
medicines. Should they cause annoyance, or be jDainful or 
irritable, they are easily dissected out. 

Xeroderma. (^See Ichthyosis and Angioma.) 



PART III. 
CUTANEOUS PHARMACOPGEIA. 



BATHS. 



1. Baths are used for cleansing purposes, to remove 
scales and crusts to allow of the application of other 
remedies, to soothe irritable skins and relieve itching, to 
lessen inflammation and soften the parts, to stimulate the 
skin and resolve infiltration, and to destroy parasites. The 
quantity of water in a bath is estimated at thirty gallons, 
and the temperature should be from 90° to 95° F. 

(a) SooTHiXG AND EMOLLIENT Baths. — The quanti- 
ties of substances to be used are either — of hran, 2 to 6 lbs.: 
of gelatine, i to 3 lbs. ; of size, 2 to 4 lbs. ; of linseed, 1 lb. ; 
or of starch, 1 lb. The starch should be beaten through a 
small quantity of the water before the bath is filled up. 
Useful in many inflammatory and irritable diseases. 

(6) An Alkaline bath is made with from §ij to gx of 
carbonate of soda or potash, or giij of borax. It is sometimes 
useful to add bran liquor, made by infusing bags of bran in 
hot water. For children, a nice bath is made by using i 
to i lb. of soft soap. Useful in urticaria, chronic eczema, 
psoriasis, lichen, prickly heat, and prurigo, where there is 
irritation or collection of scales and infiltration. In ichthy- 
osis, to remove the caked mass, a stronger bath is often 
necessary. 

(c) An Acid bath is made with §j of nitric or muriatic 
acid, or an gj of each. Used in chronic lichen and prurigo, 



214 CUTANEOUS PHARMACOPCEIA. 

and sometimes of value in urticaria, to relieve intolerable 
itching. 

(d) A SULPHUEATED POTASH BATH haS §ij to giv tO 

each bath, and is anti-parasitic, stimulant, and anti-pruritic. 
The late Mr. Startin's compound sulphur bath has §ij of 
sulphur (prsecip.), §j of hyposulphite of soda, and §ss of 
dilute sulphuric acid, mixed first of all in a pint of water. 
To this 2 lbs. of gelatine or size may be added. Used in 
itch, phthiriasis, extensive body ringworm, chronic eczema and 
psoriasis, lichen, and urticaria. 

(e) Tar Bath. — Tar the skin thoroughly, and then 
remain in a warm bath for from three to six hours. This 
procedure, carried out each day, is effective in some cases 
of prurigo, and chronic infiltrated eczema and psoriasis. 

(/) Prolonged or continual warm bathing has 
been found useful in some cases of pemphigus, pityriasis 
rubra, general eczema, and prurigo. A patient can live 
altogether in a bath, only leaving it for relief of the 
bowels, etc. 

(y) Wet packing is sometimes useful in removing 
scales or crusts or ichthyotic masses. 

FUMIGATION. 

2. To administer a medicinal vapor bath, heat is to 
be applied simultaneously to the drug and a small tray of 
water, so that steam and the vapor of the drug may arise 
together and surround the patient's naked body. Such an 
apparatus may be improvised with a chair and blankets, 
but can be obtained at a small cost at an instrument 
maker's. 

For mercurial fumigation 20 to 30 grains of pi^re calomel 
are volatilized, and the duration of the bath should be 
about fifteen minutes. Localized calomel fumigations by 
means of a special apparatus are of great use in some 



CAUSTICS. 215 

obstinate local syphilides. For a svlphiir fumigatioUy from 
1 to 2 ounces of sulphur should be used. Patients so 
treated should carefully avoid exposure to cold, and when 
treated at home can rest for a while enveloped in a blanket. 



CAUSTICS. 

3. Glycerine of Iodine. — R lodi, potassii iodidi, aa 
gss ; glycerini, 33. M. (Anderson.) To be painted on a 
patch of erythematous lupus once or twice daily for several 
days according to the effect produced, and protected by 
gutta-percha tissue. It is painful. 

4. Argenti nitratis, gr. xv ; sp. sether. nit., gj. M. 
(To be kept excluded from the light.) Used in very 
chronic eczema, psoriasis, ringworm, spreading erysipelas, and 
especially pruritus vulvce. With equal parts of water, 
silver nitrate forms a mild caustic for erythematous lupus. 

5. Chloride of Zinc Paste, Middlesex Hospital. — 
R Zinci chloridi, §j ; farinse tritici, ^ij vel q. s. ; liq. opii 
sedat. vel aquae, gj. M. A good caustic to be applied 
spread on linen rag to limited surfaces to complete the 
removal of disease after cutting or scraping, viz., in lupus, 
cancer, or rodent ulcer, 

6. Hebra's Modification of Cosme's Arsenical 
Paste. — B Arsenici alb., gr. v ; cinnabar (hydrarg. sul- 
phuret. rub.), gr.xv; ung. emoll., ^ij. M. To be applied 
thickly, spread on linen, to non-idcerated forms of lupus for 
three days, renewing the application every twenty-four 
hours. It may be used also to other 7iew growths. 

7. Vienna Paste (Potassse c. Calce). — R Potassse caus- 
ticse, calcis vivse, aa, sp. vin. rect. q. s. ut fiat pasta. Used 
to small areas of lupus; to be spread on linen, and kept 
applied for ten minutes, care being taken to protect the 
healthy skin by adhesive plaster. 



216 CUTANEOUS PHAKMACOPCEIA. 

8. Potass^ fus^, aqu^e, aa. M. This caustic causes a 
rather deep slough, extending beyond the exact area to 
which it has been applied. 

9. Fuming Acid Kitrate of Meecury. — R Hydrar- 
gyri, gj ; acidi nitrici (sp. grav. 1.40), §ij. M. To be kept 
stoppered. A very powerful caustic ; to be applied with a 
glass rod. 

10. Hydrargyri iodidi rubri, gr. x-gj ; glycerini, gss 
(or equal parts of the two ingredients may be used). M. 
A favorite French application in lupus especially. 

11. Acidi chromici, gr. Ix; aq. destillat., ^iv. M. A 
superficial caustic used for destruction of warts, A solution 
often grains to the ounce of water is very valuable to heal 
syphilitic inflammation of the tongue. 



GENEEAL APPLICATIONS. 

Alum. — 12. R Pulv. aluminis, gr. xx-xl ; (pulv. zinci 
sulphatis, gr. x-xx) ; glycerini, gj ; aquse ros^e ad iviij. 
M. ft. lotio. An astringent used in the erythemata, chronic 
intertrigo, and acne rosacea, 

13. An ointment which is useful in seborrhoea, is made 
by the addition of x-xx grains of alum to §j of benzoated 
zinc ointment, to which an equal quantity of borax may be 
added. 

Ammonia. — 14. R Ammonise hydrochloratis, gr. xx ; 
ung. zinci benzoati ad §j. Used in urticaria, 

15. R Liquoris ammon. acetatis, gij ; acidi hydrocyanici 
dil., 5j ; tinct. digitalis, ^iij ; aq. rosse ad gviij. M. ft. lot. 
Or the same with sp. vini rect, gss, substituted for the 
hydrocyanic acid and digitalis. Cooling lotions m pruritus, 
urticaria, erythemata, etc., where the skin is unbroken. 



GENERAL APPLICATIONS. 217 

Atropine. — 16. R Atropine salphatis, gr. j ; boracis, 
5ij ; glycerini, gss ; acidi hydrocyanici dil., 5J ; aq. flor. 
aurantii, gij ; aq. destillat. ad Sxij. A lotion useful to allay 
itching where the skin is unbroken. 

17. Or, Ung. atropine, 5ij ; acidi hydrocyanici dil., 3J ; 
ung. cetacei ad §j. M. ft. ung. 

Belladonna. — 18. R Extr. belladonnse, gss; acidi 
hydrocyanici diluti, §ss ; glycerini, gj ; aq. ad §xiv, A 
lotion used to soothe irritable papular and phlegmonous 
eruptions. (Startin.) Useful also in dysidrosis and herpes. 

Benzoic Acid. — 19. R Acidi benzoici, gr. xl ; boracis 
9j y g^ya^^'i^h oi^s ; aq. ad gvj. A useful lotion to relieve 
itching in urticaria. 

Bismuth is a very valuable sedative, and useful in 
many inflamed and itching conditions. 

20. Ung. Bismuthi Oleatis (McCall Anderson). — R 
Bismuthi oxidi, §j ; acidi oleici pur., §viij ; cerse albse, §iij ; 
vaselini, gix ; olei rosse, tt\^v. M. ft. ung. One of the 
most healing of salves. 

21. R Bismuthi subnitratis, Qij ; liq. plumbi diacet., gss, 
vel P. zinci oxidi, gj ; vaselini ad §j. M. ft. ung. 

22. R Bismuthi subnitratis, ^ij ; acidi hydrocyanici dil., 
3ij ; emulsionis amygdal. amar., vel aq. camph., vel aq. 
laurocerasi, vel aq. sambuci ad gviij (if the hydrocyanic 
acid is retained, to be used to unbroken skin). Used in the 
early inflammatory stages, and as a sedative in lichen 
planus. 

Boracic or Boric Acid and Borax. — 23. R 

Boracis, ^ij ; raorphise hydrochloratis, Bj ; acidi hydro- 
cyanici, 5J ; glycerinse, §j ; aq. ros^e ad gviij. (McGrath.) 
To be applied after ablution with a soft sponge, night and 

19 



218 CUTANEOUS PKARMACOPGEIA. 

morning, in pruritus vulvce and other forms of pruritus, 
Meigs recommends a somewhat similar lotion with borax, 
gss, and sulphate of morphia, gr. vij to gviij of water. 

24. B Boracis 9ij ; sodse carbonat., gj ; glycerini, giss ; 
acidi hydrocyanic! diluti, ^ss-^ij ; aq. sambuci ad §vj. 
Used in acne, seborrhcea, and to relieve itching, 

25. Ung. acidi boracici mollis, an antiseptic and 
slightly stimulant salve. R Acidi boracici, ^j ; cerse albse, 
5ss; aq. destill., ^ss ; paraffin, ^ij ; ol. amygdal., ^ij. M. 
sec. art. (Messrs. Sandford and Blake.) The last four 
ingredients melted together must be added to the very 
finely pulverized acid in a hot mortar, and incessantly 
triturated together till the mass is cold. Messrs. Savory 
and Moore, to avoid any irritation caused by particles of 
the acid, have prepared, at Dr. Thin's suggestion, a stable 
homogeneous cream, by dissolving the acid in glycerine 
and incorporating it with a fatty basis of white wax and 
almond oil. Mr. Martindale also prepares three excellent 
varieties of this ointment. 

Camphor and Chloral. — 26. R Camphorae, chloral. 

hydratis, aa 5] ; rub down thoroughly together until liquid, 
and incorporate wdth pulv. amyli §j-ij to make a dusting 
powder, which must be kept tightly corked in a wide- 
mouthed bottle. 

27. Or mix with ung. aquae rosse, §j. 

28. Or dilute with gj or more w^ater to form a lotion. 
(Bulkley.) These applications are anti-pruritic. Chloral 
is a powerful solvent and dissolves the alkaloids — e, g., 
with the lotion above mentioned morphia gr. v may be in- 
corporated {chloral glycerite of morphia and camphor). 

29. R Pulv. camphorse, gr. viij ; tinct. conii, ^ij ; ung. 
simplicis ad gj. (Neligan.) Anti-pruritic camphor is a 
good remedy to check the burning heat of eczema. {See 
F. 90.) 



GENERAL APPLICATIONS. 219 

30. R Camphor?e, ^ss-^j ; sp. vin. rect., §j ; boracis, 9ij ; 
aq. rosse ad gviij. A stimulant lotion useful to allay itchmg. 

Carbolic Acid. — 31. R Acidi carbolici, gr. x-jj ; 
solve cum glycerin, q. s. ; ung. zinci, §j (Liveing and Neu- 
mann), or the acid may be conveniently made up with 
glycerine of starch. Carbolic acid is one of the best anti- 
pruritic remedies ; it is also antiseptic and germicidal. In 
strong preparations it is an irritant, and even in weak prep- 
arations a stimulant. When applied very strong it is 
anaesthetic. It is used for pruritus, prurigo, psoriasis, lichen 
planus, infiltrated chronic eczema, and parasitic affections, 
etc., and it is freely miscible with water (gr. i-4J to §j), 
glycerine (see F. 112), alcohol and fats (ol. carbolici acidi, 
1 in 60, for pediculosis). 

32. R Acidi carbolici, tt\^xx ; ol. ricini, giv; sp. vini 
rect., Jiss; ola. mygdal. amar., v^iv. (Duhring.) Used in 
seborrhceas when not too actively inflamed, and after the 
scalp has been cleansed from crusts. 

Ohrysophailic Acid. — 33. R Acidi chrysophanici, 
gr. v-^ij ; vaselin ad gj. Used as a stimulant and alterative 
in psoriasis and some other chronic diseases, also as a para- 
siticide in ringworm. Goa powder contains 80 per cent, 
or 90 per cent, of this acid, which stains the hair and skin 
and linen, and may set up an erysipelatoid inflammation, 
especially about the head, and conjunctivitis. In ring- 
worm the surface should be wetted with acetic acid, and 
then the powder rubbed thoroughly in. 

Collodion.— 34. R Collodion flex. (B. Ph.), gj, amyl. 
hydride, §j ; aconitise, gr. j ; veratrise, gr. vj ; M. ft. appli- 
catio. (Lackerstein.) Amyl Colloid. — To be brushed over 
the painful part — e. g., herpes, ^we or six times a day, and 
protected by spongiopiline if necessary. 



220 CUTANEOUS PHARMACOPOEIA. 

Gurgun Oil. — 35. Messrs. Savory and Moore have 
prepared the following ointment and lotion, which are 
much more satisfactory than the usual lime-water liniment. 
R 01. dipterocarpi (gurgun oil), ^vj ; vaselin, ^iv ; cerse 
albse, ^ij ; ol. bergamii, ttlx ; ol. limonis, gtt. x. M. ft. ung. 

Iodine. — 36. Pasta Amyli et lodi. — R Pulv. amyli, 
part j ; glycerine, parts ij ; aquae, parts vj. Boil together, 
and when nearly cold add sol. iodi, part j. A valuable 
paste for cleansing foul sores, especially in lupus and syphilis. 

Iodoform. — 37. This anti-pruritic, stimulant, and heal- 
ing powder may be dusted on sores alone or mixed wdth 
tannin or fuller's earth ; or used as an ointment (gr. v-xx 
to §j) of vaseline or ung. petrolei, to which a little balsam 
of Peru may be added, or dissolved in 6 to 12 parts of 
ether, alcohol, warm oil, or eucalyptus, or collodion. It is 
very efficacious in indolent and chronic ulcers, ivhether 
specific, malignant, or otherwise, condylomata, cracked nipples, 
glandular swellings, lupus, ringworm, and to dry up puriflu- 
ent surfaces, 

38. Godlee recommends iodof , gr. x ; ol. eucalypti, gss- 
5J ; vaselin, gj ; as a dressing in lupus after erasion. 

Lead. — 39. Ung. plumbi oleatis (Sawyer) is made by 
thoroughly incorporating 1 part of oxide of lead with 8 
parts of oleic acid, and then 24 parts of this lead oleate 
wnth 14 of heavy and inodorous paraffin oil. It is not so 
good a sedative as the oleates of bismuth and zinc. 

40. R Ung. plumbi carbonat. (B. P.), 5J ; zinci oxidi, 5] ; 
cetacei ad gj ; oL olivae q. s. ut fiat ung. mollis. (Neumann.) 
A soothing and astringent ointment, especially useful in 
irritable seborrhoea. Chloroform, ^iv, may be added to 
allay pruritus, 

41. The Ung. plumbi comp. of the old London Phar- 
macopoeia is a very good ointment for chronic eczema. 



GENERAL APPLICATIONS. 221 

42. Ung. Diachyli Albi (Hebra). — R Olei olivie opt., 
gxv ; lithargyri, ^iij et gvj ; coque s. a in ung. molle, dein 
de adde ol. lavandulse, ^ij. This ointment is very difficult 
to prepare of the proper light yellow buttery consistence. 
Messrs. Ferris and Co., of Bristol, prepare an exceedingly 
good modification of this ointment as suggested by Eisner. 

43. Martindale's modification (Ung. vaselini plumbi- 
cum), made by thoroughly dissolving together and incorpo- 
rating equal parts of emplast. plumbi and vaseline, furnishes 
a bland emollient for inflamed surfaces. Balsam of Peru, tar, 
etc.,. may be added to make a stimulant for chronic eczema, 
and psoriasis, especially of the palms. 

44. LiQ. plumbi diacetatis may be painted on erythe- 
matous lupus. When much diluted (rr^v to §j of rose water 
or decoction of poppy-heads, etc.) it is used as an astringent 
and sedative to inflamed surfaces, whether broken or not, 
and as an anti-pruritic. In stronger solutions, with spirits 
of wine or borax and glycerine, it is used as a stimulant 
face wash (milk of roses). 

45. R Liq. plumbi diacet., §ss ; vitelli ovorum duorum; 
aquse sambuci (B. P.), Oj. Used in sehorrhcea and acne of 
the face. 

46. R Liq. plumbi diacet., z] (zinci oxidi, ,^ij) ; tinct. 
hyoscyami vel vin. opii, ^ij ; mist, camph. vel decoct, papa- 
veris ad §viij. Used in pruritus, eczema, herpes, erythema, 
etc. 

47. R Liq. plumbi subacetat., ^ss ; vin. opii, gss ; ung. 
sambuci ad §j. (Liveing.) Used in irritable eczema, her- 
pes, etc. 

48. Glyceritum Plumbi Subacetatis, or Glycerole 
of the Subacetate of Lead (Squire). — R Plumbi acetatis, 
parts V ; lithargyri, parts 3 J ; glycerine, parts xx. Heat for 
half an hour in a boiling glycerine bath, constantly stir- 
ring, and filter in a gas oven ; w^hen a clear and perfectly 
colorless liquid is obtained, to be diluted with a little 

19^ 



222 CUTANEOUS PHAKMACOPCEIA. 

glycerine and rose water for use as a lotion, or with vaseline 
for an ointment. A slightly stimulant and astringent 
application for chronic eczema, but it is not anti-pruritic, 
and does not resolve infiltration. 

Lime Water. — 49. Lin. calcis, ol. olivse, aa. A use- 
ful application for subacute inflammation. A little salicylic 
acid may be added for antiseptic purposes, or some carbolic 
acid. 

Mercury. — 50. R Calomelanos, 5J (camphorse, ^ss ; sp. 
vin. rect., q. s.) ; vaselin ad §j. Used in pruritus ani et 
vulvce, and in syphilitic ulceration. A good dusting powder 
for condylomata is formed by equal parts of calomel and 
magnesia. 

51. The oleate of mercury 5 per cent., 7i per cent., 10 
per cent., and 20 per cent. Valuable as a local application 
for syphilides, or for inunction. (Bumstead preferred the 
20 per cent, preparation mixed with an equal weight of 
simple cerate.) It is one of the best remedies for chronic 
ringworm, and Dr. Alder Smith mixes with it one-seventh 
part of acetic ether, or, to avoid any inflammatory eflfects, 
recommends the mixture of 10 per cent, of the oleate with 
90 per cent, of heavy petroleum oil. Morphia may be 
added in painful conditions. 

52. R Hydrargyri ammoniati, gr. v ; ung. zinci benzoati, 
§j. A very valuable astringent to dry up limited purulent 
secreting surfaces in impetigo from pediculi, impetigo con- 
tagiosa, and ecthyma. It is also a good parasiticide for lice, 
and it may be strengthened as required up to the Pharma- 
copoeia strength, and balsam of Peru, carbolic acid, etc., be 
added. With liq. carbonis detergens, ni,v, it is useful in 
seborrhcea. 

53. An ointment of six grains of white precipitate and 
the red oxide of mercury to the ouncg of lard constitutes 



GENERAL APPLICATIONS. 223 

the ung. mercuriale co., of Startin ; much used for psoriasis, 
seboTi'hcea, sypMlides, chronic scaly eczema, and sycosis, but 
gr. XXX of each may often be used with advantage in ring- 
worm. 

54. Ung. hydrargyri nitratis (B. Ph.) made with 
vaseline is largely used in various strengths (one-half or 
more diluted) as a stimulant and alterative to limited 
patches of psoriasis, chronic eczema, ringworm, lousiness, and 
many other diseases. (See F. 113.) Balsam of Peru and 
oil of cade may often be usefully combined with it. 

5d. R Hydrarg. nitratis, 3j ; hydrarg. nitric, oxidi, 9j ; 
ol. rusci, ^iss ; ung. zinci benzoat., gss. (Anderson.) Used 
as above. 

56. R Hydrarg. bichlor., gr. vj ; acid, hydrochlor. dil., 
3J J ^^-j 3iv ; sp. vini rectif., aq. rosse, aa gij ; glycerine, §j. 
(White and Hyde.) To be applied at night to remove tan 
and freckles, and chloasvia, and w^ashed off with soap in the 
morning. The amount of the bichloride may be carefully 
increased. 

57. R Hydrargyri bichloridi, gr. iij ; acidi hydrocyanici 
dil., gij ; mist, amygdal. amarse, gvijss. (A. T. Thomson.) 
Tinct. benzoin, chloride of ammonium, spirits of wine or of 
camphor, may be substituted for the hydrocyanic acid. 
Used in ac7ie, urticaria, pruritus, lichen planus, and syphilides. 

55. R Hydrargyri bichloridi, gr. xij ; saponis mollis, gij ; 
sp. vin. rect., ^iv ; solve et adde ol. citronellse, gj. Eub 
night and morning as firmly as possible into the eruption 
caused by ti7iea versicolor, short of causing pain. (Anderson.) 
Valuable also when rubbed in by the medical man himself 
after epilation in favus and ringworm, and in weaker solu- 
tion in animal parasitic diseases. 

Morphia and Opium.— 59. R Morphias sulphatis, 
gr. vj ; sodse biboratis, §ss; aq. ad §viij. Used in various 
forms of pruritus. 



224 CUTANEOUS PHAEMACOPCEIA. 

60. R Liq. morphise hydrochlorat., giss ; liq. potassse, 51] ; 
glycerio, §j ; aq. laurocerasi, §j ; aq. sambuci ad §xij. 
Used in pruritus — e, g., that due to lichen planus, 

61. R Pulv. opii, plumbi acetatis, aa 9j ; ung. stramonii 
ad §j. (Bulkley.) To be applied after a cold hip bath in 
pruritus ani, especially if dependent on piles, and in P. 
vulvce, herpes, etc. 

b Naphthol is a product of the distillation of tar, 
introduced as a substitute for tar in psoriasis, pruritus, 
prurigo, lichen planus, scabies, etc. It is far more agreeable, 
but highly stimulant. 

62. R b Naphthol, parts iij ; cretae pr^eparat., parts ij ; 
saponis mollis, parts x ; adipis, parts xx. M. ft. ung. for 
hospital use. (Kaposi.) 

Pyrogallic Acid, — 63. R Acidi pyrogallici, part j ; 
adipis, parts x. M. ft. ung. A stimulant salve employed in 
psoriasis especially, but only to limited surfaces. Cleanlier 
than chrysophanic acid, but less effective. 

Salicylic Acid. — 64. R Acidi salicylici, 5ss-3;j ; vase- 
lini ad §j. A non-irritating, antiseptic, and inodorous 
salve used in eczema. It is also of some value in ringworm, 
and an alcohol solution is a cleanly remedy for tinea versi- 
color. Camphor combines with salicylic acid. 

Soda. — 65. R Sodse carbonatis, 5SS ; succi conii, gj ; aq. 
sambuci ad §vj. Used to allay itching in eczema, lichen, 
urticaria, miliaria, and pruritus, 

66. R Sodse bicarbonatis, §j ; glycerini, ^iss ; aq. sambuci, 
§vjss. Used in similar conditions. Hydrocyanic acid, 
cherry-laurel water, and borax may be added. 



GENERAL APPLICATIONS. 225 

Soft Soap. — 67. Spiintiis Saponatus Kaliniis or Kali- 
creme (Hebra). R Saponis viridis/ gij ; sp. vini rect., §j ; 
solve et dein filtra, adde sp. lavand. gij. A stimulant alka- 
line lotion, used as a resolvent wash in acne, seborrhcea, and 
sebaceous lupus, to remove the sebaceous plugs and dissipate 
the infiltration: also in chronic eczema and psoriasis (see 
F. 74). 

Sulphur. — 68. R Sod?e hyposulphitis, 5] ; aq. ad gj. 
A valuable parasiticide lotion in tinea versicolor and tinea 
unguium; also useful in pruritus vulvce. 

69. R Lactis sulphuris vel sulphuris prsecip., ^ij ; ^theris, 
§ss; sp. vini rectif., ^iij ; glycerini, ^iij ; aq. rosse ad §vj. 
To be dabbed on in indolent acne and acne rosacea, and if 
much stinging is produced, to be washed ofi* after a few 
moments. 

70. R Sulphuris hypochloridi, gj-^ij (potassj^e carbonat., 
gr. x) ; adipis ad §j ; ol. amygdal. amar., gtt. x. (Wilson.) 
A stimulant ointment for acne and rosacea and infiltrated 
sycosis, to be rubbed in at night. 

71. R Sulphuris iodidi, gr. x-3;j ; adipis ad §j. A highly 
stimulant salve used in aciie. 

72. R Lactis sulphuris, glycerini, sp. vini rect., potassse 
carb., setheris sulph., aa. M. ft. pasta. (Zeissl.) To be rubbed 
at night into parts affected with comedo until a slight red- 
ness is produced. 

{See also the special remedies for parasitic diseases.) 

Tar and its derivatives are widely used in skin diseases 
for their stimulating and anti-pruritic effects ; they are also 
supposed to check cell growth. They cannot be used to 

^ This green soap varies much in composition usually. Messrs. 
Eoberts & Co., of New Bond Street, make a trustworthy compound 
containing four per cent, excess of potash. 



226 CUTANEOUS PHAEMACOPGEIA. 

acute inflammations, and discolor the skin of the face. Plx 
liquida, or Wood Tar, derived from Pinus palustris and 
other species, and Plx Mineralis vel Liilianihracis, or Coal 
Tar, are the two kinds in common use ; but Guyofs Solution 
of Wood Tar, Oleum Rusci, an empyreumatic oil obtained 
from the bark of the Betula alba, and Oleum Cadini 
(Huile de Cade) or 01. junip. empyreum., the product of 
dry distillation of the wood of Juniperus oxycedrus, and 
Wright's Liquor Carbonis Deter gens, or alcoholic solution 
of Gas Tar, are much employed in private practice, as 
more cleanly and with less smell. The U7ig. Picis (B. Ph.) 
is an effective but dirty remedy for hospital use, but the 
preparations noticed above may be made with lard, etc., 
into more cleanly ointments and lotions (see also F. 62). 

73. Glycerole of Tar (Brady). — R Glycerine, §vj ; 
picis liquid., §vj ; pulv. amyli, ^ij. Warm the glycerine, 
stir in the starch, add the tar, and raise the mixture rapidly 
to boiling point ; strain through a cloth, if necessary, and 
stir W'hilst cooling. A dark brown mass, of the same 
strength as ung. picis liquid. (L. Ph.), but perfectly smooth, 
soft in consistence, and less difficult to cleanse away. 

74. TiNCT. Saponis Viridis cum Picis (Hebra). — R 
Saponis viridis, ol. cadini vel picis liquidse, vel Guyot's 
solution of tar, sp. vini rect. vel aq. cologniensis, aa gj. M. 
ft. tinct. sec. art. It can be scented with oil of lavender 
or rosemary (33), and is used as a stimulant and resolvent 
application in psoriasis, in infiltrated eczema, and erythema- 
tous lupus, and prurigo, etc. Diluted with aqua gv, it forms 
an excellent lotion for lichen urticatus. 

75. R Acidi carbolici, 5] ; glycerini amyli, gss; ol. cadini, 
^ij ; adipis ad §j. A stimulant ointment in psoriasis, 
eczema, lichen pla.nus, prurigo, etc. In increasing the 
quantities of carbolic acid and oil of cade, a sufficient 
quantity of white wax must be added to make the ointment 
firm. 



GENERAL APPLICATIONS. 227 

76. R Liq. carbonis deterg., gij-gj ; glycerine, ^ij ; aq. 
rosie ad gviij. A stimulant used in chronic itching condi- 
tions of skin. 

77. B Liq. carb. deterg., §ss ; acidi nitrici diluti, 5j ; aq. 
camph. ad 5viij. To be sponged over irritable parts and 
then dried off with soft linen. (Startin.) Especially useful 
in pruritus and lichen planus. 

78. Liquor Picis Alkalinus (Bulkley). — R picis 
liquidse, 5J ; "^otassse causticse, 3j ; aq. destillat., ^v. Dissolve 
the potash in the water, and gradually add and rub down 
the tar in a mortar. To be used diluted from 5J-5ij to aq. 
Oj in the intolerable itching of many diseases. An oint- 
ment may be mode by adding sj-^ij to adeps §j. 

Tannin. — 79. R Acidi tannici, Z] ; vaselin, §j. M. ft. 
ung. The glycerine of tannin (B. P.) diluted is also, with 
the ointment, useful in seborrhcea. 

Thymol. — 80. R Thymol, gr. xx-^j ; solve in vaselin, 
§j. M. ft. ung. Used as a stimulant antiseptic in psoriasis, 
chronic eczema, and ringworm. The crystals are irritating. 
When rubbed dow^n with chloral hydrate or camphor, it 
liquefies, and then does not separate out in crystals on the 
addition of water. 

81. R Thymol, gss ; chloroform, ^ij ; ol. olivse ad gj. 
(M. Morris.) A mild remedy for recent ringworm. 

Turpentine. — 82. R 01. terebinthinse, ol. limonis, aa. 
A stimulant remedy for psoriasis and ringivorm. 

Zinc. — 83. R Pulv. calaminse ver., ^ij ; pulv. zinci oxidi 
pur., vel cretse prsep., 5j ; glycerin, pur., ^ss ; aq. rosse ad 
gvj. A lotion of wide application to soothe inflammatory ^'^ 

affections, to dry up slight discharges, to partially hide a 
disfiguring eruption, or Ma j pruritus. It may be variously 



228 CUTANEOUS PHARMACOPCEIA. 

modified by adding hydrocyanic acid (^j), or half the rose 
water may be replaced by liq. calcis or lotio nigra. 

84. Wilson's Ung. Oxidi Benzoatum Zinoi (BelFs 
Formula). — R Adipis prseparati, §v ; gummi benzoini pul- 
Teris, 5 j ; liquefac. cum leni calore, per horas viginti 
quatuor, in vaso clauso; dein cola per linteum, et adde 
oxidi zinci purificati, §j. Misce bene et per linctum 
ex prime. A widely used slightly astringent salve for 
inflamed surfaces. Spirits of camphor, ^ij to the gj of 
salve, may be added to allay the burning irritation of eczema. 
On uncovered parts it forms a white crust, which the 
following does not. 

85. Bulkley's Zinc Ointment. — R Pulv. zinci carbo- 
nat. pur., ^ss; ung. galeni (cold cream), gj. M. ft. ung. 
A good mild astringent and sedative for uncovered parts 
especially. 

86. Ung. Zinci Oleatis (Crocker). — R Pulv. zinci 
oxidi pur., gj ; acidi oleici (as free as possible from palmitic 
acid), gviij ; vaselini, gix. Stir thoroughly together the 
oxide of zinc and oleic acid, allow to stand for two hours, 
heat gently in a water bath, till the zinc oxide is completely 
dissolved, and when cold make into a soft ointment with the 
vaseline. One of the most soothing and emollient of salves, 
and useful in all inflammatory conditions, especially where 
the cuticle is abraded. 



PLASTEES. 

87. Emplasteum Fuscum. — R Camphor., gss ; picis 
burgund., ^vj ; cerse flav., ^ix ; plumbi oxid. rub., gij ; ol. 
olivse, giv. To be melted together till a little burned. 
Used for boils, 

88. Emplastrum Hydrargyri (Neumann). — R Hy- 
drarg., ^v ; ol. terebinth., ^ij ; cerse flav., ^iij ; emplast. 



DUSTING POWDERS. 229 

plumb., giss. Used to resolve nodules of syphilis, lupus, 
and acne rosacea, and stimulate unhealthy syphilitic iilcera- 
tlons. The formulae for emplast. hydrarg. vary much. It 
can be weakened by compounding equal parts of emplast. 
hydrarg. and emplast. saponis. 

89. Emplastrum de Vigo vel Empl. Hydrarg. Comp. 
— R Hydrargyri, 5ij ; olei terebinthin^e, n\^xx; cerse flavse, 
gr. xx; resinie, gi^- xl ; styracis, 5] ; emplastri plumbi, §j. 
Much used by the French as above. 

DUSTING POWDERS. 

A great variety of substances may be used as dusting 
powders — i.e,, for cooling, drying up, and protecting moist 
surfaces, and relieving heat and itching. The oxide and 
carbonate of zinc, alum, and the aluminous earths (Fuller's 
earth), powdered maize, wheaten starch, rice powder, lyco- 
podium pollen, talcum venetum, carbonate of magnesia, 
French chalk, carbonate of bismuth, etc. The '' violet 
powders," so widely employed, were originally made chiefly 
of the rounded, smooth, absorbent granules of starch ; but 
of late years many deleterious compounds (crystalline and 
otherwise) have been introduced under this title. Taylor's 
'Cimolite and Curtis' Pasma are reliable preparations. 

90. R Pulv. zinci oxidi, 5] ; pulv. amyli, ^vij. M. (Pulv. 
camphorse, 5], may be added to allay burning heat.) Starch 
rapidly takes on an acid reaction, and should always be 
mixed with oxide of zinc, carbonate of magnesia, etc. 

91. R Pulv. acidi salicylici, ^ij (pulv. aluminis exsic- 
cati, §iv) ; pulv. zinci oxidi vel zinci carbonat. prsecip., 
5iv ; pulv. amyli, gij. The alum may be omitted when the 
surface is much abraded. 

92. R Acidi salicylici, partj; pulv. gummi tragacan., 

parts ij ; pulv. amyli, parts iij. To be dusted on in itrti- 

caria. 

20 



230 CUTANEOUS PHARMACOPCEIA. 

93. B Camphorse, ^ss ; sp. vin rect., q. s.; pulv. talci, 
pulv. zinci oxidi, aa 3iij. To be made in small quantities, 
and kept in a stoppered bottle, and sprinkled on inflamed 
surfaces — e. g., in acute eaema, occasionally. (McCall 
Anderson.) 

Messrs. Woolley, of Manchester, prepare an excellent 
antiseptic po^'der, containing boracic acid (sanitary rose 
poivder), and Martindale's oleate of zinc powder^ can be 
usefully mixed with starch and one five-hundredth part of 
thymol. (See also F. 26 and 50.) 

SPECIAL STIMULANTS FOR THE SCALP. 

94. R Tinct. cantharid., ^vj ; glycerini, ^ij ; tinct. nucis 
vomicae, §ss ; aceti destillat., gss ; aq. rosse ad gvj. 

95. R Liq. ammonise fort., §j ; olei amygdal. dulcis, gj ; 
sp. rosmarini, giv ; aq. mellis, §ij. 

96. R Tinct. cantharid., 33 ; liq. ammon. fort., ^iij ; ol. 
macis express., ^iij ; ol. amygdal. dulcis, gj ; aq. rosse ad 
§viij. 

The above are for wide application over the scalp ; for 
alopecia areata the following are more effective : 

97. R Tinct. canthar. (vel tinct. capsici) ; glycerin, aa. 
To be mopped in thoroughly twice daily. 

98. R Tinct. canthar., tinct. capsici, aa gss; ol. ricini, 5J ; 
aq. cologniensis ad §ij. 

99. R 01. croton. tiglii, ^ss ; lin. crotonis (B. Ph.) ad §j. 

100. R Aceti canthar., 33 ; ung. hyd. oxidi rubri, vaselin, 
aa gss. 

101. R Balsami tolutani, gr. cxx ; ol. rosmarin., tt^xx ; 
tinct. canthar., ^iv ; ol. ricini, gj ; adipis prseparat., §j. M. 
ft. ung. The balsam should be dissolved in the smallest 
possible quantity of chloroform, and gradually stirred in 
with the other ingredients,* which have just previously 
been melted together. To be brushed smartly in the scalp 
night and morning. 



SCABIES AND PHTIIIRIASIS REMEDIES. 231 



DEPILATORY. 

102. R Barii sulphureti, 5iss: zinci oxicli, ^vj ; carmine, 
gr. j ; aquse q. s. ut pasta fiat. Smear over the surface, 
wash off in three minutes, when the hair comes away also. 
(Anderson.) 

REMEDIES FOR SCABIES AND PHTHIRIASIS. 

103. Schneider's modification of Vleminckx's So- 
lution. — R Sulphuris sublimat., gij ; calcis vivse, §j ; aquse 
fort., gxx ; coque ad remanent, §xij, dein filtra. A slightly 
caustic orange-colored fluid, much used in Belgium for 
scabies, and useful in inveterate acne of the hack, psoriasis, and 
prurigo, 

104. R Petrolei (commercial), giij ; ol. olivse, giss; bals. 
Peru v., ^ijss. Apply freely in pediculi capitis, and confine 
with a flannel cap. (Kaposi.) Common kerosene oil has 
also been recommended. 

105. Hardy's modification of Helmerich's Oint- 
ment. — R Sulphuris sublimat., partes duo; potassse car- 
bonat., partem unam ; adipis, partes duodecim. M. ft. ung. 

^ 106= Hebra's modification of WiLKiNSONis Oint- 
ment. — R Sulphuris praecip., olei cadini, aa gvj ; saponis 
viridis, adipis, aa Ibj ; cretse prsep., §iv. M. ft. ung. Much 
used at Vienna for scabies. To be rubbed in night and 
morning for forty-eight hours, and allowed to remain on 
the skin for one week before a bath is taken. 

107. R Sulphuris sublimat., gss ; hydrarg. ammoniati, 
gr. iv; creasoti, ^iv ; olei anthemidis, ^x ; adipis ad §j. 
M. ft. ung. (Tilbury Fox.) A mild but good remedy for 
scabies and phthiriasis. 

108. R Sulphuris sublimat., gss ; bals. Peruvianse, gss ; 
adipis ad §j. M. ft. ung. (Duhring.) Used in the scabies 
of children. 



232 CUTANEOUS PHARMACOPCErA. 

109. R Styracis liquidse, §j ; adipis, §ij. Melt and 
strain. (Anderson.) A clean, pleasant, unirritating rem- 
edy for the scabies of children, or where much inflammation 
exists. 

110. R Pulv. staphisagrise, gj ; adipis, giv. Digest to- 
gether for three hours and strain and add ol. roris, gtt. x ; 
or olei staphisagrise, 3] ; adipis, §j. M. ft. ung. Used in 
phihiriasis. (See also F. 31, 52, 62, 122.) 



REMEDIES FOR VEGETABLE PARASITIC 
DISEASES. 

111. Glycerate of Borate of Soda. — Pulv. sodse 
biboratis glycerini, aa partes 100. Triturate together in a 
glass mortar, or with gentle heat, until the solution is com- 
plete. (Gandolphe.) Especially useful in tinea versicolor, 
applied several times a day. 

112. Carbolic Glycerine. — Acidi carbolici liquefact., 
glycerini, aa. This is too strong for many skins, and the 
carbolic acid should be further diluted, even to one in five, 
according to the extent of diseased surface, and the age 
and susceptibility of the skin of the child. A cleanly, 
penetrating remedy for ringworm, to be rubbed in thor- 
oughly two or three times daily. 

113. Acidi carbolici pur. (Calvert's No. 2), ung. sul- 
phuris ; mix thoroughly without heat, and add ung. hydrarg. 
nit. (free from uncombined nitric acid). The proportions 
must be adjusted according to the age of the patient and 
the extent of the disease. Equal parts of each may be 
rubbed in night and morning to children over eleven years 
of age, and for a child under five begin with four parts of 
sulphur ointment to one part of each of the other ingre- 
dients, increasing the proportions of the latter, especially 
the citrine ointment, with the age of the child and the 



KEMEDIES FOR PAKASITIC DISEASES. 233 

diminution in extent of the patches. (Alder Smith.) A 
very good remedy in tinea tonsurans. 

114. Ung. Creasoti (Squire).— R Creasoti, gij ; cerse 
albse, §j. Solve. An irritant ointment, useful also in 
psoriasis. 

115. R Creasoti, jj ; acid. acet. glacial., ^vij ; M. ft. 
applic. To be painted on with a brush. The crusts which 
form may be bathed off, or forcibly detached to drag out 
diseased hairs. Mr. Morrant Baker uses an application of 
iodine, ^ij, dissolved in creasote, §j. 

116. Coster's Paste. — R lodinii, ^ij ; ol. picis liquid, 
(colorless oil of wood tar) ad §j. M. ft. applic. To be 
painted on with a stiff brush till a crust forms, which, 
when dry, should be removed with some force, if possible, 
and then the paste should be reapplied. 

117. R Ung. iodi, ^iij ; acidi carbolici, 3;j ; ung. sul- 
phuris ad §j. M. ft. ung. 

118. R Tinct. vel lin. iodi, ol. cadini, creasoti, aa. M. 
ft. applic. ; or sulphur may be substituted for the creasote 
in an ointment. 

119. R Cupri sulphatis vel subacetatis, gr. x-xxx ; ol. 
cadini, ^iij ; (sulphuris pr^ecip., ^iij ; hydrarg. aramoniat., 
gr. v-xx) ; adipis ad. §j. M. ft. ung. 

120. R Liq. epispastici, 5] ; zinci sulphatis vel cupri 
sulphatis, gr. xx-gij ; gallse pulv., 3;j-ij ; (bals. Peruv., 
3iss) ; vaselin ad. §j. M. ft. ung. 

121. R Hydrargyri sulphat. flav. (turbith mineral), gr. 
xv-xxx ; vaselin, §j. M. ft. ung. An irritant applica- 
tion. 

122. Ung. Sulph. Co. — Sulphuris sublimat., Ibss ; hy- 
drarg. ammoniat., hydrarg. sulph. c. sulph., aa gss ; laeviga 
simul, dein adde olei olivse, giv ; adipis recentis, gxvj ; 
creasotonis n\^xx. Misce. Useful also in scabies Siud phtJd- 
riasis. 

20- 



231: CUTANEOUS PHARMACOPCEIA. 

123. R Acidi sulphurosi recentis (sat. sol.), part j ; aqure, 
partes ij-iv. M. ft. lotio. Used in all the tinese. {See 
also F. 33, 37, 51 to 58, 64, 68, 75, 80, 81, 82, 106.) 

INTERNAL REMEDIES. 

Only a limited number of prescriptions are here pre- 
sented, and those mostly of a special character, and such 
as are not to be found for the most part in the general 
hospital pharmacopoeias. The doses, unless otherwise spe- 
cified, are for adults. 

Mercury. — 124. R Hydrargyri bichloridi, gr. 3^— §■; 
acidi hydrochlor. dil., ttlv; aqu^e ad §j. To be taken twice 
or thrice daily, after meals. To this the tinct. ferri per- 
chlor., TT]^x-xx, or liq. arsenici hydrochlor., Tr^iij, may be 
added, if necessary. 

125. R Hydrargyri bichloridi, ammonite muriatis, aa 
gr. iij ; tinct. cinchon. comp., giij ; aq., giij. (Bumstead.) 
Dose — From a teaspoonful to a tablespoonful two or three 
times daily. 

126. R Hydrargyri bichloridi, gr. ^; pulv. opii, gr. \] 
conf. rosse, q. s. M. ft. pil. (Samaritan Hospital.) 

127. Mist. Hydrargyri Iodidi (Startin). — R Hydrar- 
gyri bichloridi, 9j ; potassii iodidi, 5\^* ; tinct. iodi comp., 
5ij ; aq. q. s. ad 3xvj. M. 5j contains i gr. of bichloride 
and gr. iij of iodine. 

128. R Hydrargyri bichloridi, gr. ^; potassii iodidi, 
gr. iv ; decoct, sarsse comp. ad gj. 

129. R Hydrargyri biniodidi (rubri), gr. x2~1j ^^t- 
gentian, gr. giijss (or pulv. glycer., gr. j ; syrupi, v^]). One 
pill twice daily. The red iodide is much more active than 
the green iodide. 

130. Syrup of the Ioduretted Biniodide of Mer- 
cury. — R Hydrargyri biniodidi, gr. j ; potassii iodidi, 3J ; 



INTERNAL REMEDIES. 235 

aquse, gj. Filter through paper, and add syrupi, §v. A 
tablespoonful for a dose. A favorite form in Paris. 

131. R Hydrargyri protoiodi (virid.), gr. ^-1 ; pulv. opii, 
gr. i (vel ext. hyoscyara.) ; ext. gentian., q. s. One pill twice 
daily. This is a favorite remedy with many. 

132. R Hydrargyri bicyanidi recentis, gr. ^-y^^; quinise 
disulphatis, gr. j ; ext. gentian^e, gr. 1 J. One, two, or three 
times a day. 

133. R Pilulse hydrargyri, gr. ij ; ext. opii gr. J-J (vel 
ext. hyoscyam.). Quinise disulphas and ferri sulphas exsic. 
may be combined with blue pill and made up with treacle. 

134. R Pulv. hydrargyri cum creta, pulv. Doveri, gr. 
ijss; conf. ros^ q. s. M. ft. pil. (University.) For children, 
one or two grains of " gray powder " may be given twice or 
thrice daily in hereditary syphilis. 

Mercury and Arsenic. — 135. Donovan^ solution, or 
liq. arsenici et hydrargyri iodidi, n\^x-xx with bark. In 
chronic syphilis and other chronic diseases. 

Iodide of Potassium.— 136. R Potassii iodidi, gr. v ; 
ammon. carbonat., gr. iij (tinct. calumbse, 5ss ; aq. ad gj) ; 
vel decoct, sarsse comp. ad §j. The ammon-citrate of iron, 
or tartarated iron, or bicarbonate of potash, may be asso- 
ciated with the iodide as occasion requires. The dose of 
the iodide may be gradually increased up to gr. xxx or 
more, freely diluted with water, and taken on a full 
stomach. If ill borne, the sodium salt may be tried. 

137. R Potassii iodidi, gr. v; syr. ferri iodidi, sj. M. 
ft. mist. 

Iodine. — 138. E lodi, gr. xxiv; amyli, §j. Triturate 
the iodine with a little water (not spirit), and gradually 
add the starch until a uniform blue-black color is pro- 



236 CUTANEOUS PHARMACOPCEIA. 

duced, and then dry with a gentle heat. A full teaspoonful 
freshly prepared in a draught of water thrice daily. 

Arsenic. — 139. R Liq. Fowleri, 3iss ; ferri et amnion, 
citratis, gj ; tinct. nucis vom., ^ij ; tinct. cinchon. comp., 
§iv. (Bulkley.) A teaspoonful after meals. 

140. R Vin. ferri, giss ; syrupi simplicis vel zingiberis, 
§ss ; liq. Fowleri, gtt. xlviij ; aq. destillat. ad §vj. A table- 
spoonful twice or thrice daily, well diluted after meals. 
The dose of arsenic may be carefully increased. Children 
bear arsenic remarkably well, and it may be given con- 
veniently in cod-liver oil or in any of the iron syrups. 

141. R Liq. potassge arsenit., ^ij ; ammon. carbonat., §ss; 
potassse acetatis, §j ; syrupi, §ss ; aq. ad gxij. A table- 
spoonful in a wineglass of water thrice daily after food. 
(Anderson.) The effects of arsenic with an alkaline di- 
uretic. 

142. R Liq. arsenici hydrochlor., n|^iij-viij ; acidi hydro- 
chlor. dil., tt\^v; tinct. ferri perchlor., n\^x-xx; aq. ad 5J. 
Twice or thrice daily after meals. 

143. R Acidi arseniosi Isevig., gr.v ; pulv. acaciae, gss ; 
pulv. cinnamon, comp., ^iij ; glycerin, q. s. ut fiat pilulas c 
(pil. arsenical, comp.). One or two pills daily after meals. 
(Blackfriars' Skin Hospital.) 

144. R Acidi arseniosi, gr. j ; quinise disulphat., gr. xx- 
XXX ; ferri sulph. exsic. vel ferri redact., gr. xl-lx ; ext. 
lupuli, gr. X ; ext. gentian., q. s. Misc bene et divide in 
pilulas xvj vel xx. One twice a day after a meal. Used 
in chronic skin diseases with debility. 

145. R Sod^ arsenias, gr. ij ; ext. lactucse, gr. xx (ferri 
sulph. exsic, gr. xx) ; ext. nucis vom.,gr. iij. M. et divide 
in pil. xxiv. One pill tw^o or three times daily. 

Sulphide of Calcium. — 146. Should be given sev- 
eral times daily iu the form of pills (varnished) containing 



INTERNAL REMEDIES. 237 

Tar. — 147. R Picis liquid^e, gtt. iij-xv. In treacle 
thrice daily in chronic eczema and psoriasis, or it may be 
taken in capsules or in a pill — e. g., R Picis liqiiidie, ^ij ; 
pulv. glycyrrhiz?e, q. s. Divide in pill Ix. (Anderson.) 
Two pills to be taken thrice daily. 

Ohaulmoogra and Gynocardic Acid.— 148. The 

oil is best given in perles, or ten-minim doses may be given 
in milk or cod-liver oil. Gynocardic acid (Cottle) may be 
given in pills thrice daily, thus: R Gynocardic acid,gr. i; 
ext. gent, vel ext. lupuli vel conserv. ros^e, gr. iij ; gradu- 
ally increasing the dose. 

Gurgun Oil. — 149. R 01. gurgun, §v ; tr. quillre, §j et 
5iv ; pulv. tragacanth., jij ; sacchar. alb.,3iv ; ess. limonis, 
TTj^xx ; tinct. limonis, §j ; aq. ad §x. M. ft. emulsionem. 
Dose: A drachm to half an ounce twice daily. 

Cannabis Indica. — 150. R Tinct. cannab. Ind., TT]^v 
-XX ; mulilaginis, 5J ; aq. ad §j. To be taken every four 
hours to control intense itching. A pill may be made also 
with the extract (gr. i-gr. j). 



DIET 1^ SKIN DISEASES. 



There are one or two observations to be made on this 
subject that may be of use in the management of these 
diseases. 

First. — A distinction must be made between the diet 
of the private and hospital patient. The latter often only 
requires to be well fed up and his disease then speedily 
goes ; the former, on the other hand, often needs to have a 
check put on the quantity and quality of his food, but both 
need due attention to be paid to their excretory functions, 
that they be not sluggish. 

Secondly. — In young children, skin diseases often arise 
directly from defective alimentation, as in the case of 
eczema ; and it is frequently the case that the child, the 
subject of eczema, intertrigo, or psoriasis, has not a sufficient 
supply of milk, either from excessive dilution or otherwise ; 
or the child is being nursed by a weakly mother. 

Thirdly. — The regulation of the diet, setting aside the 
question of quantity or quality, is, as a rule, needed not so 
much to directly influence the skin disease as certain states 
of the general health, which modify the particular disease 
present ; for instance, to meet dyspeptic, gouty, and rheu- 
matic conditions especially, but particularly the former ; 
and the mode in which these act prejudicially upon skin 
diseases has been referred to in Part I. of this work. 



DIET IN SKIN DISEASES. 239 

In dyspepsia in connection with eczema, acne, psoriasis, 
lichen, or congestion of the face, it is advisable, especially 
if the urine be very acid, to avoid sugar, tea, coffee, alco- 
holics, beer, raw vegetable matter, unripe or uncooked fruit, 
veal, pork, seasoned dishes, pastry, cheese, pickles, and the 
coarser kinds of vegetables, but especially all articles whose 
use is followed by heat or flushing of the face, and by flat- 
ulence or the like. Milk, the common meats, a light kind 
of bread, and some very sound light wine should be the 
diet of dyspeptic patients, whose skins are at all in a state 
of irritation. In very many cases the stomach is at fault 
at the outset, and a careful regulation of the diet is of the 
utmost importance as an aid to the other means adopted to 
correct faults in other parts of the system. This implies 
on the part of the practitioner the possession of an accurate 
knowledge of the characteristics of the various forms of 
gastric, intestinal, and hepatic functional diseases, which is 
indeed most necessary to a successful dealing with a great 
number of skin troubles. 

In the case of gouty subjects the above remarks apply 
with special force. As regards stimulants, a good light 
claret, or whiskey in Vals water, is the best beverage. 

In strumous subjects, the diet should consist of as much 
fatty matter as possible. 

Fourthly. — In children who suflfer from ringworm, it 
is desirable to give as much fatty matter as possible, by 
means of milk, cream, eggs, and fat meat if they can 
eat it. 

Fifthly. — In syphilis, the greatest care should be taken 
to avoid anything beyond the most moderate use of stimu- 
lants ; their abuse in this disease is a source of the greatest 
aggravation ; otherwise the diet should be nutritious. 



240 DIET IN SKIN DISEASES. 

Sixthly. — In all cases in which the onset or early stage 
of a skin disease is accompanied by febrile distiirhance, how- 
ever slight, or in which the disease is very hypersemic, 
stimulants should be avoided, and the plainest and simplest 
diet ordered. In marked cases of this kind, a milk diet 
for a while is often found to be very beneficial. 

Seventhly. — In some cases in which the skin is very 
hyperceinic, this condition is much increased by the ingestion 
of food, especially if dyspepsia exists, in consequence of 
the sympathy existing between the stomach and the part 
of the skin afiTected. This state of things is especially 
marked in such diseases as acne, congestion of the face, and 
non-parasitic sycosis. Stimulants must be avoided, except 
they be diluted with some alkaline w^ater : the use of a diet 
appropriate to the dyspepsia must be rigorously enforced. 

Eighthly. — It is said that psoriasis requires an ample 
meat diet ; but the patient must be dieted, and not his 
disease — i. e., the diet should be plain and nutritious, and 
adapted to the constitutional peculiarities of the individual 
according to circumstances. 

Ninthly. — In all cases w'here a skin disease has become 
chronic, and where there is debility, the patient should be 
allowed a full, unstimulating diet. 



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